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Prof. Dr Anka Letic, DDS., PhD 

The formation of the concept of stress as an adaptive body reaction. Many studies have shown high levels of stress in doctors, dentists, teachers, and  lecturers. Recent Studies of  dental literature confirm that dentists are subject to a variety of stress-related physical and emotional problems.

These problems includ an alarmingly high incidence of cardiovascular disease, ulcers, colitis, hypertension, lower back pain, eye strain, marital disharmony, alcoholism, drug addiction, mental depression and suicide. A large number of factors are implicated, including low autonomy, work overload, and lack of congruence between power and responsibility. Doctors and dentists who take on a teaching role in addition to their clinical role may increase their levels of stress, but there is also evidence that this dual role may reduce job-related stress. Working as a doctor or dentist may entail higher levels of stress than are experienced by the general population. In some situations adding in the role of teacher reduces this stress, but more research is needed to explain this finding.

Despite the dominance of a negative attitude to stress in society, it is important to recognize that stress  is initially an adaptive response of the body allowing it to counter various influences. The common stress is the No. 1 killer in the modern world.  It is convincingly countered by the words of the  founder of the concept of stress, Hans Selye: “Stress is the salt of life. Complete elimination of stress... would be the same as death”.

ACTIVATION OF THE HYPOTHALAMO-HYPOPHYSEAL-ADRENOCORTICAL SYSTEM – A KEY COMPONENT OF THE STRESS REACTION

Fig. 1

Many contemporary aspects of the study of the problem of stress are associated with the key hormonal axis of the stress reaction – the hypothalamo-hypophyseal-adrenocortical system (HHACS) (Fig.1). The development of this area of study is the incarnation of his insightful suggestion of the existence of hypothalamic corticotropin-releasing factor (CRF), “the first stress mediator.” CRF is the main neurohormone involved in activating the hypophyseal-adrenocortical axis in stress. The gastrointestinal tract in general and the stomach in particular are very sensitive to various stress situations. Gastric ulcer disease, which is a common pathology, is regarded as a “stress-related disease”.

Studies and statistics – Dentist under the stress

Nearly half of dentists (48%) suffer of stress, followed by patient complaints (32%), compliance (30%), money (29%) and work-life balance (26%) (Fig.2). Other significant causes of stress included conflicts between team members (21%), dealing with phobic or anxious patients (20%) and gappy appointment books (20%). As a comparison, results for the team as a whole demonstrated that running late was the major cause of stress (52%), with conflicts between team members showing next at 32%, followed by work-life balance at 28%.  The stress suffered by dentists appears to cause a significant incidence of physical symptoms, with nearly a half (45%) suffering from insomnia; other significant symptoms include tiredness (43%), anxiety (40%), bruxism (31%), headaches (30%) and depression (27%) amongst others. Only 15% stated they had experienced no physical symptoms from their stress. So what about you? What stresses you out and how do you cope with the stress? The 30-40 years of age group scored highest in exhaustion. The score of professional efficacy decreased with age and increased with educational levels. Role overload, responsibility, physical environment, reaction and self-care were major predictors for exhaustion. Role insufficiency, role overload and responsibility were major predictors for cynicism. Role insufficiency, social support and rational/cognitive were major predictors for professional efficacy.  The suicide rate of dentists is more than twice the rate of the general population and almost three times higher than that of other white collar workers.  Emotional illness ranks third in order of frequency of health problems amongst dentists, while in the general population it ranks tenth.  Coronary disease and high blood pressure are over 25% more prevalent among dentists than in the general population.  Dentists suffer psycho-neurotic disorders at a rate of 2 1/2 times greater than physicians.  The #1 killer of dentists is stress-related cardiovascular disease.  The dental profession in North America loses the numerical equivalent of one large dental school class each year. Why is our profession so prone to stress-related physical, mental and social problems? Since it is unfortunately too late for most of us to switch into law or engineering, at least we can examine some of the causes of stress in dental practice and then see if we can find some solutions to them and hopefully live a little longer and happier.

The average dentist spends most of his or her life confined to a small, sometimes windowless, 7ft. by 9ft. operatory, which is smaller than the cells in our penal institutions. The work is intricate and meticulous and is performed in a small, restricted oral space. The procedures are both physically and mentally taxing and as a result, strain, back troubles, circulatory disorders and fatigue are common. It is relatively easy, over a period of time, for a dentist to become both physically and emotionally "burned-out."

Most dentists practice alone, they are isolated. Consequently they do not have the opportunity to share and solve problems with their colleagues the way other professional groups do through peer support. The problem of isolation is compounded by the fact that dentists tend to be competitive with one another. This trait is unfortunately a bi-product of our competitive dental school training. It is then reinforced after graduation by the intense competition created by the surplus of dentists that now exists in many cities and large metropolitan areas.

The relentless pursuit of perfection and permanence in an inhospitable oral environment is a major cause of stress and frustration for dentists. The stress of perfection is instilled in dental school. However, it must be tempered with the realization that the most perfect restoration will ultimately be rendered imperfect by time and patient neglect, despite the efforts of the dentist.

Economic pressure forces many dentists to work through their lunch -- an hour that is the single most important period of the work day.  

Instead of using the time to get proper nourishment and much needed rest, he or she will often accommodate an additional patient or two. This inevitably leaves the dentist tired and exhausted by the end of the day.

Another result of the economic pressure of practice is that dentists often feel that they literally cannot afford to be sick or take holidays. When a dentist is absent from the office, the income totally stops, but the high overhead expenses continue to grow relentlessly.

The dentist who works all the time and never takes time off  might make a few dollars more, but there is a high price to pay -- BURNOUT! And when dentists burnout, they become emotionally and mentally exhausted, develop a negative, indifferent or cynical attitude towards both their patients and their staff, and evaluate themselves negatively.

Attempting to stay on schedule in a busy dental practice is a chronic source of stress. Dentistry, unfortunately, seems to be governed by Murphy's Law -- "If anything can go wrong, it will go wrong and usually at the worst possible time." Also, dentists often find that the first 90% of a complicated dental procedure takes 90% of the allotted time and the last 10% takes another 90%. And as we all know, once we are behind schedule there is no way to catch up.

A dentist spends many years in dental school learning perfection and "ideal" treatment for his or her future patients. Yet the realities of private practice are that many patients, due to financial restraints, poor insurance plans or low appreciation of quality dental care, will not accept "ideal" treatment plans. The result is that the dentist is continually forced to compromise treatment and is frustrated in not being able to reach his or her ideal treatment goals. Consequently, the dentist is often forced to operate a "fix-and-repair" business, providing compromised treatment for patients who refuse the full spectrum of dental care. The dentist then ends up emotionally carrying the responsibility for less than ideal results while the patient continues to express unrealistic expectations.

The psychological stress of working with apprehensive and fearful patients can be devastating to the dental practitioner.  

There is now considerable evidence that dentists experience patterns of physiological stress responses (increased heart rate, high blood pressure, sweating, etc.) that parallel the patient's responses when performing dental procedures that evoke patient fear and anxiety. This in turn can lead to an early heart attack for the dentist.

Researchers are finding that many personality traits that characterize a good dentist are also traits that predispose to depression in mid-life, drug and alcohol abuse and the attendant risk of suicide. Among such traits are: (1) compulsive attention to details; (2) extreme conscientiousness;  (3) careful control of emotions; (4) unrealistic expectations of himself or herself and others (i.e. employees and patients); (5) a marked dependence on individual performance and prestige.

The Pankey Institute in Miami evaluated the health of 2,400 dentists. It found that the dentist's life was characterized by Dormancy, Degeneration and Stress (i.e. DDS). Also, dentists do not exercise enough to prevent progressive deterioration of connective tissue, small blood vessels, muscles and circulation in general.

Managing stress

 

Stress can never be totally eliminated from dental practice. However, it must be minimized as much as possible in order to avoid the many stress-related physical and emotional problems that it causes. The key to managing stress successfully is to first recognize and understand its causes. Once the causes have been identified and understood, preventive steps can be taken. Some of the preventive measures that could minimize the stress of dental practice are as follows:

-Improving the working environment at the office;

-Becoming less isolated and sharing problems with fellow practitioners;

-Working more sensible hours and taking time each day for a leisurely lunch break;

-Taking holidays whenever the pressures of practice start to build;

-Learning how to better handle patient anxiety and hostility;

-Adopting a program of physical exercise, such as regular walking or working out at a local health club.

Ergonomics is the science that studies human stress and strain related to activities,  and has one primary objective-to prevent work related musculoskeletal disorders, or symptoms that aggravate these disorders. Smart business owners have adopted the practice of ergonomics as an integral element in their ongoing strategies to increase productivity and ensure reduced workers' compensation liability. Audiometric data of both ears, gathered with an interval of 10 years, were analyzed.  Sensory tests of the fingers were performed for dominant and non-dominant hands in relation to exposure time to (ultra)sonic equipment. Positive responses for the questionnaire were as follows: low back pain, 54% (stress-correlated); vision problems, 52.3% (age-correlated); infections, 9%; allergies, 22.5% (mainly latex); stress level was scored 7 on a scale from 0 to 10; diminished sensitivity of the fingertips, 6% and auditory disorders, 19.6%. Pilot audiometric data showed a hearing loss at 4,000 Hz for the left ear, presumably indicative of occupational noise trauma. The two-point discrimination ability of the dominant hand tended and vibration hand neuropathy to diminish in line with the number of years of practice.

 

References

ADA Bureau of Public Information News Release. Temple University School of Dentistry Study of dentist suicide rates. 1997.

Alexander RE. Stress-related suicide by dentists and other health care workers: fact or folklore? JADA 2001; 132:786-94.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Washington: American Psychiatric Press; 1994Gale EN. Stress in dentistry. N Y State Dent J 1998; 64(8):30-4.

Humphris G. A review of burnout in dentists. Dent Update 1998; 25:392-6.

Moore R, Brodsgaard I. Dentists' perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol 2001;29:73-80.

Caso, J. C. Leza,  L. Menchen, “The effects of physical and psychological stress on the gastro-intestinal tract: lessons from animal models,” Curr. Mol. Med., 8, No. 4, 299–312 (2008).

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