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Dentistry is a demanding profession that carries a significant risk of mental health challenges due to high levels of work-related stress.1-3 A 2021 American Dental Association survey based on a nationally representative sample revealed that more than 70% of participants experienced moderate or severe work-related stress, particularly female practitioners and those under age 40.4 In the United Kingdom, a survey of more than 2,000 dentists showed that over half (54.9%) experienced high workplace stress, with 44% struggling to cope with it. Alarmingly, around 10% reported suicidal thoughts in the previous year.5 The authors also reported lower life satisfaction, meaningfulness, and happiness and higher anxiety levels in dental care providers compared to the general population.5 General dental practitioners experience higher stress levels and lower quality of life than dental specialists.3,5,6
There are multiple primary stress dimensions in dental practice that contribute to burnout, a condition that involves physical and mental tiredness, low energy, and overall weariness; these stress dimensions include patient-related and job-related issues, regulatory concerns, and personal challenges.3 The COVID-19 pandemic increased pressure on oral health providers due to the risk of viral exposure, higher infection control standards, reduced patient flow, and financial strain.7,8 A post-pandemic survey of Welsch dentists revealed that one-third of participants increased the frequency of alcohol consumption.9 Research suggests that dental practitioners became more susceptible to work-life imbalance and neglect of their personal health after the pandemic.9,10
Chronic stress is a robust driver of chronic disease development and poor quality of life. The profound physiological and psychological effects of chronic stress disrupt homeostasis, increasing the risk of various conditions. Higher risks for cardiovascular disease, diabetes, obesity, autoimmune disorders, bruxism, tiredness, insomnia, and elevated mortality are associated with chronic stress.11,12 Occupational stress in dentistry has also been linked to a higher risk of developing mental health problems, such as depression, anxiety, and burnout.13 Its detrimental effects are directly mediated by dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis and indirectly via unhealthy coping mechanisms.14,15
The mental, emotional, physical, and biological challenges associated with dental practice can result in the development of unhealthy coping responses to stress.16 In a survey among Saudi Arabian dentists, the most frequently reported coping mechanisms for high-stress levels were watching television, using electronics, and binge eating.17 A high prevalence of alcohol consumption was reported in a survey of UK dentists, with 22% surpassing the recommended national guidelines.5 In addition to the physical and psychological challenges associated with chronic stress, it can significantly impact practitioners' personal and professional relationships and negatively affect clinical decisions and patient care.18
Despite the highly detrimental effects of chronic stress, this topic and its impact on dental care providers have been under-addressed in the dental literature.9,19 The reasons for this possibly include limited awareness, stigma, a focus on clinical skills, lack of research, normalization of the condition, an emphasis on maintaining a professional culture, and inadequate support despite growing recognition of the issue.20 This narrative review examines the prevalence, implications, and triggers of stress within the dental profession, emphasizing the pressing need for understanding and addressing this issue. By shedding light on mental health in dental practice, this article advocates for increased support in dental education and practice, aiming to lessen the associated stigma of mental health needs and enhance the well-being of dental professionals.
Prevalence of Stress and Mental Health Concerns
Overwhelming professional and personal demands and consequent high-stress levels are matters of growing concern in dentistry.5 Numerous studies have consistently indicated that dental professionals face a notable burden of stress due to the unique challenges of the profession, contributing to mental health issues such as burnout, depression, and anxiety.21-25 Table 1 provides an overview of studies reporting prevalence percentages of stress and its mental health consequences.
Chronic stress is an adaptive physiological and psychological response to challenges that exceed an individual's ability to cope effectively. The stress response is complex, involving the nervous system, endocrine system, and various organs and functions, and triggering a cascade of physiological changes.26 Theliterature shows that 25% to 86% of dental practitioners from different countries have high work-related stress.4,5,21-25 The stress spectrum of common mental conditions typically progresses from anxiety to burnout, depression, and suicidal ideation (Figure 1).
Anxiety is an adaptive emotional response that physiologically prepares the body to respond to real or imagined threats. It can manifest as frequent and repetitive worry, fear, and apprehension. Studies report that 4.3% to 78.8% of dental providers present anxiety symptoms.27-30
Workplace burnout is another consequence of chronic stress and is formally recognized by the World Health Organization as a medical condition that progresses gradually.31,32 The initial phase of burnout is emotional exhaustion; this encompasses physical and mental tiredness, low energy, and overall weariness. The second stage, depersonalization, is marked by reduced empathy, irritability, skepticism, negativity, and a tendency to distance oneself emotionally from work. The final stage of burnout is characterized by low personal accomplishment, including diminished self-worth, low work performance, depression, a consistently negative outlook, avoidance of social interactions, self-perception aligned with failure, and a limited capacity to address challenges.33,34 While various methodologies and cultural differences introduce variables in burnout research, most studies indicate elevated burnout levels within dentistry, impacting 1.05% to 83.6% of professionals (Table 1).21,23-25,27,30,35-46 Regarding the distinct elements of burnout, emotional exhaustion has been observed in 8.3% to 61.3%, depersonalization in 9.5% to 65.8%, and low personal accomplishment in 4% to 41.4% of dental professionals (Table 1).46-53 Two systematic reviews reported an overall burnout prevalence of 13% among dentists, with 25% presenting emotional exhaustion, 18% presenting depersonalization, and 32% having low personal accomplishment.54,55
Depression is another mental condition linked to the stress spectrum. It is described as pervasive hopelessness, sadness, and a general loss of interest in many aspects of life, affecting emotions, thoughts, behavior, and physical health.56 Self-reported depression has been noted in 9% to 60% of surveyed dental practitioners from different countries.27-29,57,58
Unchecked, stress-induced mental health issues can intensify and worsen over time. In a recent Australian study, researchers stated that 17.6% of dental practitioners had experienced thoughts of suicide within the previous year, while 31.4% had such thoughts prior to the previous year. Additionally, 5.6% of participants disclosed a history of having attempted suicide.29
The dental literature highlights that specific professional subgroups, including female practitioners, young professionals, and general practitioners, exhibit increased vulnerability to elevated stress levels.5,38,49,58,59 These statistics serve as an urgent call to action for dental institutions, organizations, employers, and professionals to address the pressing mental challenges within the dental profession.20
Factors Contributing to Stress in Dentistry
Dentistry demands a unique, wide-ranging skill set that includes emotional resilience, extensive medical knowledge, dexterity, optimal communication skills, and diagnostic capabilities. Dental practitioners navigate multiple daily challenges related to patients, the job itself, financial complexities, legal matters, and the practitioner's own personality. These factors are summarized below.53,60
Patient-Related Stressors
Patient traits. Dealing with patients with dental anxiety or phobias can be emotionally draining. Dentists may need to employ special techniques and require extra time to calm patients and provide the necessary care.53 In a 2018 German survey, dental practitioners regarded about one-quarter of their patients as challenging. Participants reported multiple patient characteristics that can create difficulties, including anxiety, criticism, aggression, interrogation, lack of cooperation, rudeness, and obsessive-compulsive traits. There was an association between poor patient behavior and the dentist's susceptibility to burnout, with anxious and aggressive patients being the most challenging.61 Other studies suggest that complaining patients and patients with high expectations also put pressure on dentists for fear of patient dissatisfaction.41,53,62
Clinical mistakes. The pervasive fear of making mistakes in clinical dentistry can lead to heightened stress levels, impacting practitioner well-being and patient outcomes. In a study from Hong Kong that included more than 1,000 dentists, the fear of making clinical mistakes ranked top on the dentistry stressors list.53
Job-Related Stressors
Patient perception. While dentistry is generally viewed as a respectable profession, patients sometimes still associate dentists with the experience of pain and discomfort.63 In a South African survey, 56.3% of dentists reported that being perceived as an inflictor of pain was highly stressful.41
Workload. The demanding nature of clinical dentistry significantly contributes to a substantial workload, both perceived and actual. Dentists, particularly practice owners, frequently extend their work hours. The work may encompass not just patient care but also administrative responsibilities, contributing to elevated fatigue levels and a higher vulnerability to burnout.40,53
Time pressure. The unpredictability of biological and patient factors, the complexity of numerous dental procedures, and tight daily schedules often place dentists in situations where complicated tasks must be performed quickly. Time constraints adversely affect diagnostic accuracy and sensitivity. According to a 2019 UK study, the ability to detect caries and periodontal disease decreased by 40% and 67%, respectively, under time constraints.64 Running behind schedule can promote stress and anxiety, lower the quality of patient care, and increase the risk of burnout.53,60
High concentration. Dentists must maintain unwavering focus during clinical procedures. The pressure to make quick, informed decisions in unexpected situations further underscores the need for sharp concentration and diagnostic abilities. This continual demand for mental acuity can elevate stress levels.41,65
Dealing with emergencies. Dentists must be ready to adeptly manage unforeseen dental and medical emergencies and unanticipated complications that frequently involve highly stressful situations.62,65,66
Continual learning. Dentistry is a continuously evolving field. The perpetual quest to stay up-to-date with the dynamic landscape of emerging knowledge, evolving clinical techniques, and advancing technologies presents an enduring challenge for dentists.67
Career advancement. Similar to other healthcare professions, dentists often encounter stress related to career advancement. This can manifest in various ways, primarily stemming from the pursuit of higher qualifications and aspirations of practice ownership.3
Isolation. Dentists often work in solo or small practices, which offers autonomy but can foster professional isolation given limited peer interaction. A lack of a support network can induce loneliness and disconnectedness, ultimately elevating stress levels.41,68,69
Work environment. Dentists may encounter interpersonal conflicts involving staff, colleagues, or patients, creating workplace challenges related to communication and interpersonal dynamics.24,60
Financial and Regulatory Stressors
Financial pressure. The financial complexities of managing a dental practice, including factors such as overhead costs and insurance claims, frequently act as stressors, which can be compounded by educational financial commitments and ongoing investment in equipment and technology.24,41,65
Legal and regulatory compliance. Dentists must adhere to a multitude of local, state, and national regulations and stringent standards. In addition, the fear of litigation and malpractice claims can create anxiety and stress.3,5,69
Personal Stressors
Work-life balance. Balancing work and personal life is a common challenge for dentists, especially practice owners who must manage business operations while delivering quality dental care. These responsibilities can strain family life and personal relationships.69
Health concerns. Providing dental care can expose dentists to infectious diseases and other occupational health risks, such as ocular injuries, hearing impairment, and allergies, adding to their stress load.70
Physical demands. Dentistry involves repetitive motions and awkward body positions for extended periods, increasing the risk of developing musculoskeletal disorders, including shoulder, neck, and back pain.30,40
Perfectionism. While perfectionism can promote clinical excellence, it can also contribute to elevated stress levels and burnout due to unrealistic expectations and self-imposed pressure.71,72
The multifaceted nature of stressors in dentistry underscores the importance of dedicating time and effort to developing stress resilience for a sustainable and rewarding career as a dental practitioner.
Impacts of Elevated Stress Levels
Physiological Consequences
Chronic stress triggers the production of cortisol via the aforementioned HPA axis, initiating a complex physiological response that influences the immune system, metabolism, inflammation, and the gut microbiome. This chronic stress response is a risk factor for various health conditions, including cardiovascular disease and gastrointestinal issues.11,62
Muscle tension and musculoskeletal disorders can also be aggravated by stress.73 Research reports a high annual prevalence (68% to 100%) of work-related musculoskeletal disorders in dental practitioners, with the back, shoulder, and neck being the most affected areas.30,74,75 Rising et al noted that by the third year of dental education, more than 70% of dental students reported musculoskeletal pain irrespective of gender.76 Inadequate ergonomics, repetitive movements, and suboptimal posture during clinical procedures contribute to postural strain, adversely affecting the musculoskeletal system.73
Psychological Consequences
A substantial body of evidence highlights the intricate relationship between mental health issues and chronic stress within the dental profession. Failing to address chronic stress adequately can ultimately increase the risk of unhappiness, loneliness, low quality of life, illness, and suicide.2,53,57,71
Although the evidence regarding suicide rates among dentists is inconsistent, alarming statistics have been reported (10% to 17.6% prevalence of suicidal ideation).5,29 Among the general population in the United States, approximately 4% of adults experience suicidal thoughts annually.77 In 2011, a Danish study reported there was an elevated risk of suicide within the healthcare profession, with dentists exhibiting the highest suicide rate of 7.18% (8.02% for male dentists and 5.28% for female dentists).78 In comparison, the national average suicide rate was substantially lower, at 0.42%. This data underscores that dentists are 2.5 to 4.4 times more likely to take their own lives.
Behavioral Consequences
Multiple neurobiological mechanisms have been linked to stress-induced behavioral changes involving mood, cognition, social interactions, and coping strategies. These include HPA axis activation, neurotransmitter imbalances, neuroinflammation, and changes to the hippocampus, amygdala, and prefrontal cortex.79
Elevated work-related stress among dental practitioners has been linked to reduced sleep and exercise and increased alcohol consumption.62 A study conducted in Australia found that 15% to 20% of surveyed dentists exhibited hazardous alcohol consumption patterns, underscoring how stress-induced alterations in lifestyle can exacerbate the impact of chronic stress on overall health.5,80 At work, chronic stress and its consequences can manifest as increased absenteeism, aggression, conflicts, a higher rate of errors, diminished quality control and productivity, and lowered morale, ultimately affecting professional performance, clinical decision-making, and the quality of patient care.67
Conclusion
Persistent chronic stress exerts profound effects that influence a dentist's health and well-being and leave their mark on one's career, personal life, and family relationships. Dentists play a vital role in enabling patients to maintain their overall health; therefore, the ability of dentists to cope with stress is crucial for both their own sake and the well-being of their patients. Prioritizing proactive stress management is of utmost importance to safeguard the welfare of not only dentists but also their staff and patients, thus helping to ensure a sustained and satisfying career.
About the Authors
Carla Cruvinel Pontes, PhD, MSc, DDS
Certified Health Coach, Researcher, Mouth-Body Research Institute, Greyton,
South Africa
Kyle Stanley, DDS
Private Practice, Founder, Light Side Dentistry, Beverly Hills, California
Shervin Molayem, DDS
Private Practice in Periodontics, Director of the Mouth-Body Research Institute,
Los Angeles, California; Fellow, International College of Dentists
Queries to the author regarding this course may be submitted to authorqueries@broadcastmed.com.
References
1. Jahic IM, Bukejlovic J, Alic-Drina S, Nakaš E. Assessment of stress among doctors of dental medicine. Acta Stomatol Croat. 2019;53(4):354-362.
2. Rada RE, Johnson-Leong C. Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc. 2004;135(6):788-794.
3. Toon M, Collin V, Whitehead P, Reynolds L. An analysis of stress and burnout in UK general dental practitioners: subdimensions and causes. Br Dent J. 2019;226(2):125-130.
4. American Dental Association. 2021 Dentist Well-Being Survey Report. Updated February 1, 2022. https://ebusiness.ada.org/Assets/docs/101863.pdf. Accessed March 18, 2024.
5. Collin V, Toon M, O'Selmo E, et al. A survey of stress, burnout and well-being in UK dentists. Br Dent J. 2019;226(1):40-49.
6. Abraham SB, Alsakka Amini AM, Khorshed NE, Awad M. Quality of life of dentists. Eur J Dent. 2018;12(1):111-115.
7. Which occupations have the highest potential exposure to the coronavirus (COVID-19)? UK Office for National Statistics. May 11, 2020. https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/articles/whichoccupationshavethehighestpotentialexposuretothecoronaviruscovid19/2020-05-11. Accessed March 18, 2024.
8. Raudenská J, Steinerová V, Javůrková A, et al. Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic. Best Pract Res Clin Anaesthesiol. 2020;34(3):553-560.
9. Owen C, Seddon C, Clarke K, et al. The impact of the COVID-19 pandemic on the mental health of dentists in Wales. Br Dent J. 2022;232(1):44-54.
10. Pai S, Patili V, Kamath R, et al. Work-life balance amongst dental professionals during the COVID-19 pandemic - a structural equation modelling approach. PLoS One. 2021;16(8):e0256663.
11. Agorastos A, Chrousos GP. The neuroendocrinology of stress: the stress-related continuum of chronic disease development. Mol Psychiatry. 2022;27(1):502-513.
12. Kivimäki M, Bartolomucci A, Kawachi I. The multiple roles of life stress in metabolic disorders. Nat Rev Endocrinol. 2023;19(1):10-27.
13. Stress in dentistry - a study. Dentistry.co.uk. February 2, 2012. https://dentistry.co.uk/2012/02/02/stress-dentistry-study/. Accessed March 18, 2024.
14. Heikkilä K, Fransson EI, Nyberg ST, et al. Job strain and health-related lifestyle: findings from an individual-participant meta-analysis of 118,000 working adults. Am J Public Health. 2013;103(11):2090-2097.
15. Jackson JS, Knight KM, Rafferty JA. Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course. Am J Public Health. 2010;100(5):933-939.
16. Mainous AG 3rd, Everett CJ, Diaz VA, et al. Life stress and atherosclerosis: a pathway through unhealthy lifestyle. Int J Psychiatry Med. 2010;40(2):147-161.
17. Aldhuwayhi S, Shaikh SA, Mallineni SK, et al. Occupational stress and stress busters used among Saudi dental practitioners during the COVID-19 pandemic outbreak. Disaster Med Public Health Prep. 2022;16(5):1975-1981.
18. Yansane A, Tokede O, Walji M, et al. Burnout, engagement, and dental errors among U.S. dentists. J Patient Saf. 2021;17(8):e1050-e1056.
19. Antoniadou M. Quality of life and satisfaction from career and work-life integration of Greek dentists before and during the COVID-19 pandemic. Int J Environ Res Public Health. 2022;19(16):9865.
20. Westgarth D. Mental health in dentistry: has the profession opened up through the years? BDJ in Pract. 2022;35(6):18-22.
21. Ab-Murat N, Mason L, Kadir RA, Yusoff N. Self-perceived mental well-being amongst Malaysian dentists. Int J Occup Saf Ergon. 2018;24(2):233-239.
22. Siddiqui MK, Taqi M, Naqvi S, et al. Levels of perceived stress according to professional standings among dental surgeons of Karachi: a descriptive study. BMC Oral Health. 2022;22(1):243.
23. Kay EJ, Lowe JC. A survey of stress levels, self-perceived health and health-related behaviours of UK dental practitioners in 2005. Br Dent J. 2008;204(11):E19.
24. Pouradeli S, Shahravan A, Eskandarizdeh A, et al. Occupational stress and coping behaviours among dentists in Kerman, Iran. Sultan Qaboos Univ Med J. 2016;16(3):e341-e346.
25. Anzar W, Qureshi A, Afaq A, et al. Analysis of occupational stress, burnout, and job satisfaction among dental practitioners. Work. 2022;72(1):323-331.
26. Anisman H, Merali Z. Understanding stress: characteristics and caveats. Alcohol Res Health. 1999;23(4):241-249.
27. Song KW, Choi WS, Jee HJ, et al. Correlation of occupational stress with depression, anxiety, and sleep in Korean dentists: cross-sectional study. BMC Psychiatry. 2017;17(1):398.
28. Puriene A, Aleksejuniene J, Petrauskiene J, et al. Self-perceived mental health and job satisfaction among Lithuanian dentists. Ind Health. 2008;46(3):247-252.
29. Hopcraft MS, Stormon N, McGrath R, Parker G. Factors associated with suicidal ideation and suicide attempts by Australian dental practitioners. Community Dent Oral Epidemiol. 2023;51(6):1159-1168.
30. Revankar VD, Chakravarthy Y, Naveen S, et al. Musculoskeletal disorders and mental health-related issues as occupational hazards among dental practitioners in Salem City: a cross-sectional study. J Pharm Bioallied Sci. 2017;9(suppl 1):S228-S230.
31. Atroszko PA, Demetrovics Z, Griffiths MD. Work addiction, obsessive-compulsive personality disorder, burn-out, and global burden of disease: implications from the ICD-11. Int J Environ Res Public Health. 2020;17(2):660.
32. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-111.
33. Leiter MP, Maslach C. Latent burnout profiles: a new approach to understanding the burnout experience. Burnout Res. 2016;3(4):89-100.
34. Maslach C, Leiter MP, Schaufeli W. Measuring burnout. In: Cartwright S, Cooper CL, eds. The Oxford Handbook of Organizational Well Being. Oxford, UK: Oxford University Press; 2008.
35. Denton DA, Newton JT, Bower EJ. Occupational burnout and work engagement: a national survey of dentists in the United Kingdom. Br Dent J. 2008;205(7):E13.
36. Calvo JM, Kwatra J, Yansane A, et al. Burnout and work engagement among US dentists. J Patient Saf. 2021;17(5):398-404.
37. Baran RB. Myers Briggs Type Indicator, burnout, and satisfaction in Illinois dentists. Gen Dent. 2005;53(3):228-234.
38. Pozos Radillo BE, Tórrez López TM, Aguilera Velasco Mde L, et al. Stress-associated factors in Mexican dentists. Braz Oral Res. 2008;22(3):223-228.
39. Abdi K, Mehrabadi VA, Baghi V, et al. Prevalence of occupational stress among Iranian physicians and dentist: a systematic and meta-analysis study. Przegl Epidemiol. 2022;76(3):352-361.
40. Marklund S, Mienna CS, Wahlström J, et al. Work ability and productivity among dentists: associations with musculoskeletal pain, stress, and sleep. Int Arch Occup Environ Health. 2020;93(2):271-278.
41. Bhat S, Nyathi N. Perceptions of stress among dentists: an investigation of stress management among dental practitioners in South Africa. South African Dent J. 2019;74(2):55-61.
42. Arora S, Knight A. Questionnaire survey of burnout amongst dentists in Singapore. Int Dent J. 2022;72(2):161-168.
43. Alemany Martínez A, Berini Aytés L, Gay Escoda C. The burnout syndrome and associated personality disturbances. The study in three graduate programs in dentistry at the University of Barcelona. Med Oral Patol Oral Cir Bucal. 2008;13(7):E444-E450.
44. Molina-Hernández J, Fernández-Estevan L, Montero J, González-García L. Work environment, job satisfaction and burnout among Spanish dentists: a cross-sectional study. BMC Oral Health. 2021;21(1):156.
45. Cobo-Vázquez CM, Martín C, Sáez-Alcaide LM, et al. Burnout syndrome assessment among Spanish oral surgery consultants: a two populations comparative pilot study. Med Oral Patol Oral Cir Bucal. 2022;27(1):e1-e9.
46. Gómez-Polo C, Casado AMM, Castaño A, Montero J. Epidemiological study on burnout in Spanish dentists: underlying psychological factors. Int J Environ Res Public Health. 2021;18(24):13418.
47. Jin MU, Jeong SH, Kim EK, et al. Burnout and its related factors in Korean dentists. Int Dent J. 2015;65(1):22-31.
48. Slabšinskienė E, Gorelik A, Kavaliauskienė A, Zaborskis A. Burnout and its relationship with demographic and job-related variables among dentists in Lithuania: a cross-sectional study. Int J Environ Res Public Health. 2021;18(8):3968.
49. Gómez-Polo C, Casado AMM, Montero J. Burnout syndrome in dentists: work-related factors. J Dent. 2022;121:104143.
50. Alves da Silva RAD, Macedo Teixeira AK, Arcanjo Frota MM, et al. Job satisfaction and burnout among oral healthcare providers within the Unified Health System in Sobral, Ceará, Brazil. Rev Bras Med Trab. 2020;17(3):313-324.
51. Noori F, Kazemeini SK, Owlia F. Determination of professional job burnout and temperament (Mizaj) from the viewpoint of Traditional Persian Medicine and work-related variables among Iranian dentists: a cross-sectional study. BMC Psychol. 2022;10(1):94.
52. Na Nakorn S, Srisintorn W, Youravong N. Factors associated with burnout among dentists in public hospitals, southern Thailand. J Dent Sci. 2022;17(4):1656-1664.
53. Choy HB, Wong MC. Occupational stress and burnout among Hong Kong dentists. Hong Kong Med J. 2017;23(5):480-488.
54. Moro JDS, Soares JP, Massignan C, et al. Burnout syndrome among dentists: a systematic review and meta-analysis. J Evid Based Dent Pract. 2022;22(3):101724.
55. Long H, Li Q, Zhong X, et al. The prevalence of professional burnout among dentists: a systematic review and meta-analysis. Psychol Health Med. 2023;28(7):1767-1782.
56. Netterstrøm B, Conrad N, Bech P, et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol Rev. 2008;30:118-132.
57. Ahola K, Hakanen J. Job strain, burnout, and depressive symptoms: a prospective study among dentists. J Affect Disord. 2007;104(1-3):103-110.
58. Mathias S, Koerber A, Fadavi S, Punwani I. Specialty and sex as predictors of depression in dentists. J Am Dent Assoc. 2005;136(10):1388-1395.
59. Puriene A, Aleksejuniene J, Petrauskiene J, et al. Occupational hazards of dental profession to psychological wellbeing. Stomatologija. 2007;9(3):72-78.
60. Hill KB, Burke FJT, Brown J, et al. Dental practitioners and ill health retirement: a qualitative investigation into the causes and effects. Br Dent J. 2010;209(5):E8.
61. Goetz K, Schuldei R, Steinhäuser J. Working conditions, job satisfaction and challenging encounters in dentistry: a cross-sectional study. Int Dent J. 2019;69(1):44-49.
62. Myers HL, Myers LB. "It's difficult being a dentist": stress and health in the general dental practitioner. Br Dent J. 2004;197(2):89-93.
63. Murray E, Kutzer Y, Lusher J. Dentists' experiences of dentally anxious patients in a specialist setting: an interpretative phenomenological analysis. J Health Psychol. 2019;24(3):288-298.
64. Cave V, Hutchison C. Does time pressure impact on dentists' diagnostic performance? Evid Based Dent. 2019;20(3):81-82.
65. Ayers KMS, Thomson WM, Newton JT, Rich AM. Job stressors of New Zealand dentists and their coping strategies. Occup Med (Lond). 2008;58(4):275-281.
66. Rosenberg M. Preparing for medical emergencies: the essential drugs and equipment for the dental office. J Am Dent Assoc. 2010;141(suppl 1):14S-19S.
67. Naidoo S. Managing stress in the dental environment. South African Dent J. 2015;70(9):388-389.
68. Hayer N, Wassif HS. A lonely business: reflections on the wellbeing and morale of dental teams. Br Dent J. 2019;226(8):559-561.
69. Gallagher JE, Colonio-Salazar FB, White S. Supporting dentists' health and wellbeing - workforce assets under stress: a qualitative study in England. Br Dent J. 2021. doi: 10.1038/s41415-021-3130-9.
70. Banakar M, Bagheri Lankarani K, Jafarpour D, et al. COVID-19 transmission risk and protective protocols in dentistry: a systematic review. BMC Oral Health. 2020;20(1):275.
71. Hopcraft MS, McGrath R, Stormon N, Parker G. Mental health, psychological distress and burnout in Australian dental practitioners. Aust Dent J. 2023;68(3):160-170.
72. Teixeira H, Lalloo R, Evans JL, et al. An exploratory study of perfectionism, professional factors and psychological well-being of dentistry academics. Aust Dent J. 2021;66(2):175-181.
73. Hussein A, Mando M, Radisauskas R. Work-related musculoskeletal disorders among dentists in the United Arab Emirates: a cross-sectional study. Medicina (Kaunas). 2022;58(12):1744.
74. Soo SY, Ang WS, Chong CH, et al. Occupational ergonomics and related musculoskeletal disorders among dentists: a systematic review. Work. 2023;74(2):469-476.
75. Hayes MJ, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg. 2009;7(3):159-165.
76. Rising DW, Bennett BC, Hursh K, Plesh O. Reports of body pain in a dental student population. J Am Dent Assoc. 2005;136(1):81-86.
77. Piscopo K, Lipari RN, Cooney J, Glasheen C. Suicidal thoughts and behavior among adults: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. September 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.pdf. Accessed March 18, 2024.
78. Hawton K, Agerbo E, Simkin S, et al. Risk of suicide in medical and related occupational groups: a national study based on Danish case population-based registers. J Affect Disord. 2011;134(1-3):320-326.
79. Marcolongo-Pereira C, Castro FCAQ, Barcelos RM, et al. Neurobiological mechanisms of mood disorders: stress vulnerability and resilience. Front Behav Neurosci. 2022;16:1006836.
80. Winwood PC, Winefield AH, Lushington K. The role of occupational stress in the maladaptive use of alcohol by dentists: a study of South Australian general dental practitioners. Aust Dent J. 2003;48(2):102-109.
