P R A C T I C E M A N A G E M E N T ABSTRACT

Background. Dentists encounter

numerous sources of professional stress,
beginning in dental school. This stressDcan
A
have a negative impact on theirJpersonalA
and professional lives. ✷

Stress, burnout,
✷

Conclusions. Dentists are prone to pro-

N
CON

IO
fessional burnout, anxiety disorders and
anxiety and depression

T
T

A
clinical depression, owing to theN nature of

I
C
A UING EDU 1
R T traits
clinical practice and the personality
ICLE
among dentists common among those who decide to pursue
careers in dentistry. Fortunately, treatment
modalities and prevention strategies can
help dentists conquer and avoid these
ROBERT E. RADA, D.D.S., M.B.A.;
disorders.
CHARMAINE JOHNSON-LEONG, B.D.S., M.B.A.
Practice Implications. To enjoy satis-
fying professional and personal lives, den-
tists must be aware of the importance of
entistry can be a stressful profession. This

D
maintaining good physical and mental
statement undoubtedly would invoke a great health. A large part of effective practice
deal of discussion, illustrated with personal management is understanding the implica-
experiences, from many practicing dentists. tions of stress.
Dentists encounter numerous sources of
stress beginning in dental school. On entering clinical
practice, they can find that the number
Stress can and variety of stressors often grow. Clin- sense. The same stressors that are stimu-
icians experience numerous workplace, lating or challenging in a positive sense
have a negative
financial, practice management and also may be debilitating if they accumu-
impact on societal issues for which they often are late too rapidly. It is believed that setting
dentists’ unprepared. For some dentists, these unrealistic goals generates much of the
personal and issues may significantly affect their negative stress people feel. These goals
professional physical health, mental health or both. may include the need for a particular stan-
lives. Clinical disorders such as burnout, anx- dard of income or technical perfection.
iety and depression may result. These Although setting lofty goals and high stan-
disorders may have certain negative dards is a noble theory, how people do this
effects on dentists’ personal relationships, professional can create a load that often becomes
relationships, health and well-being. Fortunately, treat- unbearable.1
ment modalities and prevention strategies can help den- How much stress a person can tolerate
tists conquer and avoid these disorders. The only limita- comfortably varies not only with the accu-
tion is their willingness to take care of themselves. mulative effect of the stressors, but also
Stress can be defined as the biological reaction to any with such factors as personal health,
adverse internal or external stimulus—physical, mental amount of energy or fatigue, family situa-
or emotional—that tends to disturb the organism’s tion and age. Stress tolerance usually
homeostasis. If the compensating reactions are inad- decreases when a person is ill or has not
equate or inappropriate, they may lead to disorders. had an adequate amount of rest. During
However, stress is not all bad. Certain stressors inspire major life changes (birth of a child, serious
people to make a greater effort; for example, a particu- accident to family member or oneself,
larly demanding patient may motivate a dentist to work divorce, death, geographic relocation),
at an exceptionally high level, resulting in the creation people’s ability to tolerate stress also is
of a highly esthetic and natural-looking restoration. reduced. Past experience enhances
Some stressors can stimulate people to grow profession- people’s ability to manage stress and
ally and personally, learn or improve. Stress is really an develop coping skills. After several similar
essential part of our lives.1 experiences, people normally learn a stand-
“Stress” is a term that often is used in a negative ard way to cope with a particular stressor.

788 JADA, Vol. 135, June 2004

Copyright ©2004 American Dental Association. All rights reserved.
 P R A C T I C E M A N A G E M E N T

Our stress tolerance TABLE

often will vary
according to the
PSYCHOLOGICAL EFFECTS OF STRESSFUL
people who surround SITUATIONS.*
us; being surrounded STRENGTH OF DURATION OF STRESSORS
by significant and STRESSORS
supportive others can Short Term Medium Term Long Term
help people resist the
effects of stress. Den- Weak— Bored, restless, Torpidity, loss of Dismay,
tists and dental auxil- Low Demands lethargic direction, disillusionment,
helplessness depression, sense of
iaries who like each failure, alienation
other and work well Moderate— Challenged, enjoy- Achievement,
Aroused, lively,
together can reinforce Challenging fun ment, satisfaction, feeling of adequacy
one another and help Demands self-efficacy or competency, high
self-esteem
raise one another’s
tolerance of stress.1 Strong— High arousal, Anger, fear, worry, Anxiety,
Excessive tension, tiredness, accom- depression,
Demands excitement plishment (if exhaustion, loss of
STRESS AND coping) self-confidence
DENTISTRY
* Adapted with permission of the publisher from Payne.8
Dentists perceive den-
tistry as being more stressful than other occupa- dentists is lower back pain. Other physical mani-
tions.2 A study of more than 3,500 dentists found festations include headaches and intestinal or
that 38 percent of those surveyed always or fre- abdominal problems. Among the psychological
quently were worried or anxious.3 Moreover, 34 disorders associated with stress are anxiety and
percent of the respondents said that they always depression. While in most cases these disorders
or frequently felt physically or emotionally are not so severe that they require intervention,
exhausted, and 26 percent said they always or they may interfere with the dentist’s professional
frequently had headaches or backaches. These performance and quality of life.2
symptoms often are associated with anxiety and The stress-related problems associated with
depression. Problems with time management and dentistry arise from the work environment and
staying on schedule appeared in several surveys.2-7 the personality types of the people who choose the
It is interesting to note that anxious patients profession. The operatory usually is small, and
often create less stress for dentists than running the dentist’s focus is on an even smaller space,
behind schedule. Other stressors that appear in the oral cavity. Dentists are required to sit still
these surveys include coping with difficult or for much of their workday, making very precise
uncooperative patients, the workload, govern- and slow movements with their hands, while
mental interventions and a constant drive for their eyes remain focused on a specific spot. Isola-
technical perfection. tion from other dentists also is common. Addition-
When humans are exposed to challenging envi- ally, a study has shown that dentistry tends to
ronments, they exhibit a broad range of physiolog- attract people with compulsive personalities, who
ical and emotional responses that vary in type and often have unrealistic expectations and unneces-
strength, according to how well they can cope with sarily high standards of performance, and who
the demands. When people evaluate their work require social approval and status.9
environment for its effect on their stress and satis- In general, as dentists’ number of clinical expe-
faction, they need to examine the nature of work riences increase, they report a lower overall per-
demands, the control given to people dealing with ception of stress. Only stress resulting from office
the demands, the support they receive from other management remains high, despite the dentists’
people in the work environment and the support practice experiences.10 This may be, in part, a con-
they receive in terms of resources.8 sequence of dental assistants’ perception of stres-
The table lists some of the psychological effects sors as being different from those of the dentists
of stress. Many of the psychological signs of stress with whom they work. Role ambiguity, underuse
manifest themselves as physiological responses. of skills and low self-esteem are important factors
The physical disorder reported most frequently by contributing to stress among dental assistants.

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P R A C T I C E M A N A G E M E N T

Unfortunately, dentists receive relatively little order and generalized anxiety disorder, or GAD.
training in the interpersonal dimensions of prac- In panic disorder, feelings of extreme fear and
tice management, so they may lack the skills to dread strike unexpectedly and repeatedly for no
remedy these conflicts.11 apparent reason, and they are accompanied by
intense physical symptoms. These symptoms may
PROFESSIONAL BURNOUT include “a pounding heart”; feeling sweaty, weak,
One of the possible consequences of chronic occu- faint, dizzy, flushed or chilled; having nausea,
pational stress is professional burnout.12 Burnout chest pain, smothering sensations, or a tingly or
is defined by three coexisting characteristics. numb feeling in the hands; a sense of unreality or
First, the person is exhausted mentally or emo- a fear of impending doom; or loss of control. Panic
tionally. Second, the person develops a negative, attacks, one manifestation of panic disorder, can
indifferent or cynical attitude toward patients, occur at any time, even during sleep. Some
clients or co-workers; this is referred to as deper- people’s lives become so restricted that they avoid
sonalization or dehumanization. Finally, there is normal, everyday activities such as grocery shop-
a tendency for people to feel dissatisfied with ping or driving.19 Panic disorder affects 2.4 mil-
their accomplishments and to evaluate them- lion adult Americans and is twice as common in
selves negatively. The effects of women as in men.18 Panic disorder
burnout, although work-related, often is accompanied by other
often will have a negative impact on Burnout is best serious conditions such as depres-
18,20
people’s personal relationships and described as a gradual sion, drug abuse or alcoholism,
13,14
well-being. and it may lead to a pattern of
erosion of the person.
Burnout is best described as a avoidance of places or situations
gradual erosion of the person. One where panic attacks have occurred.
study showed that certain aspects Panic disorder is one of the more
of dental practice, such as time pressures, treatable of the anxiety disorders, as, in most
patient-related problems and management of cases, patients with panic disorder respond to
auxiliary staff, all were relevant stressors. How- treatment with medications or carefully targeted
ever, lack of career perspective was the most cru- psychotherapy.19
12
cial aspect in the development of burnout. It is GAD involves much more than the normal
interesting to note that health professionals who amount of anxiety people experience from time to
burn out relatively early in their careers were time. It is characterized by chronic exaggerated
more likely to stay in their chosen career and worry and tension, even though little or nothing
adopt a more flexible approach to their work rou- has provoked it.19,21 “People with GAD seem to be
tines. This suggests that burnout does not neces- unable to shake their concerns, even though they
sarily have to result in far-reaching negative con- usually realize that their anxiety is more intense
sequences.15 Researchers who looked at three than the situation warrants. Their worries are
types of clinicians found that general dentists and accompanied by physical symptoms, including
oral surgeons had the highest levels of burnout fatigue, headaches, muscle tension, muscle aches,
and that orthodontists had the lowest levels of difficulty swallowing, trembling, twitching, irri-
burnout.16,17 tability, sweating and hot flashes. When impair-
ment associated with GAD is mild, people with
ANXIETY DISORDERS the disorder may be able to function in social set-
Anxiety disorders are serious medical illnesses tings or in a job. If the impairment is severe, GAD
that affect approximately 19 million Americans.18 can be debilitating, making it difficult to carry out
Each anxiety disorder has its own distinct fea- ordinary daily activities.”19 GAD affects about 4
tures, but all anxiety disorders are bound million adults in the United States, and it com-
together by the common theme of excessive, irra- monly is treated with medications.18,22 It rarely
tional fear and dread. Unlike the relatively mild, occurs alone and often is accompanied by another
brief anxiety caused by a stressful event such as a anxiety disorder, depression or substance abuse.20
business presentation, anxiety disorders are If the worry or anxiety becomes debilitating—
chronic and relentless and can grow progressively interfering with work, sleep or engaging in plea-
worse if not treated.19 Two common and poten- surable activities—it is time to seek treatment. In
tially overlapping anxiety disorders are panic dis- general, two types of treatment are available for

790 JADA, Vol. 135, June 2004

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 P R A C T I C E M A N A G E M E N T

anxiety disorders: medication and psy- BOX 1

chotherapy. The choice of which to use
depends on the patient’s and physician’s SYMPTOMS ASSOCIATED WITH
preference and on the particular anxiety DEPRESSION.*
disorder. The major classes of medica-
tions used are antidepressants, such as dFrequent depressed mood, most of the day, nearly
every day
the new selective serotonin reuptake dDiminished interest or pleasure in all or almost all
inhibitors and monoamine oxidase activities
inhibitors, and antianxiety medications dSignificant weight loss or weight gain
dFrequent insomnia or hypersomnia
like benzodiazepines.19,23 dPsychomotor agitation or retardation
dFrequent fatigue or loss of energy
DEPRESSION dFeelings of worthlessness or inappropriate guilt
dIndecisiveness or decreased ability to think or concentrate
A leading cause of disability in the dRecurrent thoughts of death or suicidal ideation
United States is major depressive dis-
order, which affects approximately 18.8 2 7
* Sources: Gale, Gorter and colleagues and National Institute of Mental
million adults in the United States in a Health. 24

given year.24 While major depression can

develop at any age, the average age of
onset is in the mid-20s. Depressive disorder often are a variety of antidepressant medications and
occurs with anxiety disorders and substance psychotherapies that can be used. Some people
abuse.18,24-26 with milder forms of depression may do well with
Major depression is an illness that involves the psychotherapy alone. People with moderate-to-
body, mood and thoughts. It affects the way severe depression most often benefit from taking
people eat, sleep, feel about themselves and think antidepressants. Most do best with combined
about things (Box 12,7,24). According to the treatment: medication to gain symptom relief rel-
National Institute of Mental Health, “A less atively quickly and psychotherapy to learn more
severe type of depression, dysthymia, involves effective ways to deal with life’s problems,
long term, chronic symptoms that do not disable, including depression (Box 218). Self-help is essen-
but keep one from functioning well or feeling tial, in that people must exert a strong willing-
good.”24 A depressive disorder is not the same as a ness to participate in activities that will help
passing blue mood, and it is not a sign of personal them manage the illness.
weakness or a condition that can be willed or
wished away. Without treatment, symptoms can STRESS, DEPRESSION AND ANXIETY IN
DENTISTS
last for weeks, months or years. Depressive ill-
nesses often interfere with normal functioning Many of the personality traits that characterize a
and cause pain not only to those who have the good dentist also can predispose dentists to
disorder, but also to those who care about them. depression. Studies have indicated that both anx-
Much of this pain is unnecessary, as many people iety and depressive disorders are observed fre-
do not recognize that depression is a treatable quently in dentists.2,5,9 Despite the fact that den-
illness. tists have been portrayed as being prone to
Often, a combination of genetic, psychological commit suicide, there is no statistical evidence to
and environmental factors is involved in the onset support this, and most reliable evidence suggests
of depression. Those people who have low self- the opposite.27 Dentists do tend to enjoy better
esteem or are pessimistic in nature can be more physical health and live longer than people in
prone to depression as well.24 Later episodes of ill- other occupations, but their mental health has
ness typically may be precipitated by only mild been shown to be poorer.28,29 Overall, the medical
stresses or none at all. community has been shown to exhibit a relatively
The first step in getting appropriate treatment higher level of depression than other professional
for depression is undergoing a physical examina- groups.30,31 Complicating this situation is the fact
24
tion by a physician. If a physical cause for the that health care providers can be embarrassed by
depression is ruled out, a psychological evaluation the thought of seeking professional help.2 Cer-
should be done. The choice of treatment will tainly, this is an area in which more study is
depend on the outcome of the evaluations. There needed.

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P R A C T I C E M A N A G E M E N T

BOX 2 COPING WITH STRESS

HOW TO HELP YOURSELF IF YOU ARE The goal of coping with stress is to offset
DEPRESSED.* the negative effects of stress by using
appropriate coping strategies. The litera-
dSet realistic goals. ture suggests that stress management
dBreak large tasks into small ones.
dTry to be with other people and to confide in someone. programs should be directed at two levels
dParticipate in activities that may make you feel better. of practitioners: dental students and den-
dParticipate in mild exercise, go to a movie or a ballgame, tists. Studies5,34-36 have emphasized the
or participate in religious, social or other activities.
dExpect your mood to improve gradually, not immediately. importance of stress management training
dPostpone important decisions until the depression has during dental education. Box 3 lists the
lifted. components that have been suggested as
dPractice positive thinking that will replace the negative
thinking that is part of the depression. essential for the dental education cur-
dLet your family and friends help you. riculum. It also has been suggested34 that
the dental curriculum be modified so that
18
* Source: Regier and colleagues. students have a chance to work outside
the dental school in a general practice
environment.
BOX 3
Practicing dentists also can benefit
from using stress management tech-
STRESS MANAGEMENT COMPONENTS niques. Stress management workshops
NECESSARY IN DENTAL EDUCATION.* focusing on stress relievers may include
deep breathing exercises; progressive
dFinancial and business management
dDevelopmental psychology (enabling an understanding of effective relaxation of areas of the body;
the person’s fears and needs at different stages of life) listening to audiotapes of oral instructions
dDynamics of stress and anxiety (enabling the dentist to on how to relax; meditation; information
understand the patient’s fear of dentistry and the dentist’s
own occupational stress)
on the topics of practice and business
dInterpersonal communication skills or how to deal with management, time management, commu-
conflict and confrontation nication and interpersonal skills; and the
dInterviewing skills and effective listening skills
dManagement of difficult, uncooperative, anxious and use of social support systems such as
aggressive patients study groups or organized dental meet-
dStress management procedures (for example, relaxation, ings.37 These workshops should be struc-
hypnosis, desensitization, time management and cognitive
coping skills)
tured to help improve dentists’ coping
skills and equip them to deal more effec-
5 34 35
* Sources: Moller and Spangenberg, Atkinson and colleagues and Cecchini. tively with the stressors intrinsic to the
profession. Professional help or counseling
services may be necessary if the effects of
Many dentists develop stress disorders early stress are affecting the person’s normal lifestyle.37
in their careers. Two studies conducted in the Researchers have found that dentists who take
United Kingdom have shown increasing evi- on teaching or leadership roles with other profes-
dence of stress-related problems in young den- sionals in addition to their clinical practice roles
tists and dental students.32,33 Stressors in the may find that it mitigates stress.38 The reasons for
early years of practice come from the combined this are speculative. The researchers suggest that
effects of the number of patients to be seen in a some reasons may be lessened isolation, increased
day, finances in general, not knowing what to self-esteem in response to the attention of stu-
expect as an associate, the fear of litigation and dents, a sense of autonomy over what and when to
making mistakes, and the belief that patients teach, power over those in a more junior position,
can be too demanding. The studies found that a added interest in patients as a source of teaching
high proportion of dental students and young opportunities, and a sense of helping the students’
dentists drank excessively and experimented future patients.
with illicit drugs. In the final year of training, The Canadian Dental Association has organized
67 percent of the students had experienced pos- support networks,9 and the Massachusetts Dental
sible pathological anxiety. Association organized one of the first support net-

792 JADA, Vol. 135, June 2004

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 P R A C T I C E M A N A G E M E N T

works when a group of dentists who formerly profession.

abused alcohol and drugs formed the Committee Stress can elicit
on Alcoholism and Chemical Dependency. The varying physio-
California Dental Association established a Hot- logical and psy-
line Referral Service for its members that provides chological
confidential counseling to dentists who are experi- effects on a
encing problems with alcohol, drug addiction or Dr. Rada maintains a At the time this article person.
practice in general was written, Dr.
mental illness. The ADA also offers a variety of dentistry, LaGrange, Johnson-Leong was With profes-
resources to help dentists cope with stress. Ill., and is a clinical assistant director, sional burnout,
assistant professor, General Practice Resi-
Physical exercise, such as regular walking or Department of Oral dency, and a clinical people become
working out at a health club, cannot be underesti- Medicine and Diag- assistant professor, emotionally
nostic Sciences, Department of Oral
mated as a stress reliever. Such activities result in University of Illinois Medicine and Diag- and mentally
burning up the additional supply of adrenaline College of Dentistry, nostic Sciences, exhausted;
Chicago. Address University of Illinois
that results from stress, and they allow the body’s reprint requests to Dr. College of Dentistry, develop a nega-
functions to return to a more normal state. Phys- Rada at 1415 West Chicago. She now is in tive, indifferent
47th St., LaGrange, Ill. private practice,
ical fitness offers a greater energy reserve, 60525, e-mail Pembroke Pines, Fla. or cynical atti-
allowing people to become more energetic and “[email protected]”. tude toward
more efficient. In addition, exercise helps develop patients, clients
greater self-esteem, self-control and self-discipline. or co-workers; and evaluate themselves nega-
People’s personalities and temperaments have tively. Two common anxiety disorders are panic
a significant impact on their percep- disorder and GAD. Both disorders
tions of stress.39 It has been Some stress is can be debilitating, as they elicit
observed that people who display excessive, irrational fear and dread.
inherent in dental
high levels of decisiveness, are self- The treatment options available are
reliant, maintain high self-worth practice, requiring medications (for example, anti-
and have developed good problem- that dentists learn anxiety medications and anti-
solving and information-seeking coping strategies to depressants) and psychotherapy.
skills cope better under stressful minimize the effects Depression affects the body, mood
conditions. Those who have strong, of stress. and thoughts. Its onset often
positive self-images and know how involves a combination of genetic,
to relax so as to reduce mental and psychological and environmental
emotional pressures also cope better factors. However, episodes of
with stress, as do people who are open to being depression may be precipitated by mild stresses.
helped by others. Some stress is inherent in dental practice,
However, not all stress-producing situations in requiring that dentists learn coping strategies to
the dental practice can be eliminated. Stressors minimize the effects of stress. Stress management
such as failing to meet personal expectations, should be targeted to dental students and prac-
seeing more patients for financial reasons, ticing dentists. The dental educational curriculum
working quickly to see as many patients as pos- should be modified to include business manage-
sible for financial reasons, earning enough money ment, stress management and communication
to meet lifestyle needs and being perceived as an skills. Some dental associations offer stress man-
inflictor of pain are all stress-producing situations. agement workshops, professional help, counseling
These issues generally require a reassessment of services and support networks. In addition, den-
one’s own attitudes and expectations in the light tists should assess their own attitudes and expec-
of whether they are realistic, achievable or tations to determine if they are realistic, achiev-
rational. able or rational. Finally, dentists must realize that
help is readily available if the effects of stress
CONCLUSION become overwhelming. ■
Dentists often perceive dentistry as being
The authors thank Dr. Anne Koerber for her valuable comments
stressful. The sources of stress arise from the about this article.
work environment (for example, workplace, finan-
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P R A C T I C E M A N A G E M E N T

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