Evaluation of Stress and Self-Perceived Barriers among Pediatric Dentists during the Dental Treatment of Children in Bengaluru City, India

Introduction

Stress is “the physical and psychological response to threatening or challenging situations”. It occurs after a situation or event is deemed onerous or exceeds personal, social, or other resources.¹ Dentistry is regarded as one of the stressful professions. Pediatric dentists are entrusted with the responsibility of restoring the oral health of a child, and transforming them into individuals with a positive attitude toward dentistry; however, the endeavor to achieve these goals can lead to stress. Pediatric dentists are often exposed to the temper tantrums of children which involves crying, jerking, anger, and avoidance behavior. The behavior management problems in children and expectations and behavior of accompanying parents can lead to stress. Additionally, the need to be cost-effective adds to this stress and fatigue.^2,3,4,5,6 Although, studies on the stress levels of general practitioners treating pediatric patients are available, the literature on the stress levels in pediatric dentists during the treatment of children is scarce. The present study was thus performed to evaluate the stressors and identify the challenges a pediatric dentist encounters during the treatment of a pediatric patient.

Materials and Methods

The present study is a descriptive, cross-sectional study. The Ethics approval for the study was obtained from the Review Board of the institution. A self-administered questionnaire along with a covering letter describing the study and the voluntary nature of participation was posted across Bengaluru city. A prepaid envelope was included for returning the completed forms. The questionnaire determined the demographic details of the participants, following which it was divided into 2 parts. The 1st part assessed the stressors and the 2nd part determined the challenging aspects of dental treatment in children. A 5-point Likert scale, where 0 = never, 1 = rarely, 2 = sometimes, 3 = often, and 4 = Always, was used to record the participant’s responses.

The stress levels were assessed using the following scale constructed to determine the stress category:

≤ 20 score - No Stress

21- 25 score - Mild Stress

26 - 30 score - Moderate Stress

> 30 score -Severe Stress

The completed questionnaires were analyzed for the responses. Descriptive statistics, frequency, and percentage analysis were used for categorical variables and mean and standard deviation for continuous variables. The categorical data were analyzed by the Chi-square test. The p-value <0.05 was considered statistically significant.

Results

Among the 80 questionnaires distributed, about 60 responses were received accounting for a 75% response rate. The participants’ age ranged from 28–52 years (mean age -35.37+6.34 years). About 31.7% (n=19) and 68.3% (n=41) of the participants were male and female respondents, respectively. The age and gender distribution of the participants are represented in Table 1. 

On the evaluation of the experience (Table 2), the majority of the participants (45%) had less than 5 years of experience, followed by 21.7% with 5–10 years and 21.7% with 11–15 years. About 8.3% of the participants had an experience of > 20 years, while only 3.3% fell in the category of 15–20 years of experience.

The stress levels amongst the participants were determined based on parameters such as the age of the pediatric patient, cooperation, and parental presence/ absence in the operatory. The majority of the respondents (n=28; 46.6%) exhibited moderate stress with a score ranging from 26–30 (mean score 27.54+1.32). Only 8.3% (n=5) of the respondents demonstrated severe stress (mean score 32.80+1.30). About 36.6% (n=21) showed mild stress (mean score 22.95+1.36) and 10%. respondents (n=6) did not exhibit any stress (Table 3).

On comparing the stress levels with the demographic characteristics (Table 4), respondents aged <35 years exhibited “moderate” stress (56.3%) in comparison to those above 35 years (45.5%). However, respondents above 35 years demonstrated “severe” stress levels compared to < 35years. However, no statistically significant difference was observed. Female respondents exhibited significantly higher “moderate” stress (58.3%) compared to male respondents (38.3%). However, “severe” stress levels were more in males (22.2%) compared to females (2.8%). Comparing the stress levels based on experience suggested that respondents with an experience of <5 years showed more stress levels compared to those with >5 years of work experience. The difference was not statistically significant.

It was observed that the most challenging aspect of treating the children was physical strain (75%) and behavior management problems (60.7%) that were responsible for “moderate” stress among the respondents (Table 5). Parental attitude (42.9%) and time management (28.6%) constituted other causes of stress among the respondents. Financial feasibility caused mild stress in 75% of the respondents. However, the occurrence of “severe” stress was low. The difference in stress levels due to behavior management problems was statistically significant.

Local anesthesia administration (68%), followed by cavity preparation (66.7%), and tooth extraction (50%) were the most difficult treatment procedures in children that contributed to “moderate” stress among the participants (Table 6). Isolation (55%) and recording of impressions (75%) in children contributed to mild stress among the respondents.

The results demonstrated that crying (60%) and temper tantrums (60%) followed by stubbornness of the pediatric patient contributed to moderate stress among the participants. Crying also contributed to severe stress among 40% of the respondents. Furthermore, temper tantrums also contributed to severe stress among 16% of the participants.

On comparing the association between stress levels and the most challenging dentition stage; mixed dentition (65.4%) followed by permanent dentition (50%) caused “moderate” stress compared to the deciduous dentition stage.

The results elicited that about 30% of the respondents had stopped the treatment midway for a child; the most common reason being stress (50%) followed by non-cooperative behavior (38.9%), parental interference (38.9%), fatigue (33.3%), and procedural error (22.2%).

Discussion

Research indicates that dentistry causes more stress in comparison to other professions and job-related factors describe the majority of the comprehensive stress in a dentist’s life.⁷ Dentists experience an array of stressors in their work environment including time-related pressures, heavy workloads, anxious or difficult patients, staffing issues, equipment failures, defective materials, and the routine aspects of the job that place them at risk for chronic occupational stress and burn-out.^8,9

The present survey aimed to evaluate the levels of stress in pediatric dentists and to determine the challenging aspects of providing oral care to children.

An elevation in stress may adversely affect the performance of the dentists, which can be threatening to the physical and mental well-being of the patients. Newton et al¹¹ suggested that pediatric dentists are more stressed in comparison to other specialists. Humphris and Peacock¹² proposed that treating children is the primary reason for the stress in the UK community dental service. General practitioners, periodontologists, and pediatric dentists are regarded as the most stressed specialists.¹³

In the present study respondents aged <35 years showed more stress compared to those above 35 years. Furthermore, on comparing the stress levels based on experience, respondents with <5 years of experience exhibited more stress in comparison to those with >5 years of experience. The negative correlation between stress levels and experience can be attributed to better exposure, observational learning, and maturity with an increase in experience. Ronneberg et al¹⁴ reported stress as an important factor among 60% of the cases with less than 10 years of work experience. According to Pouradeli et al¹⁵, dentists who have less work experience are prone to feel more stressed than those who have work experience of more than 10 years.

The female participants exhibited more stress scores than the male participants. Women experience more stress than men because they are more sensitive and probably get affected by environmental stress factors easily.¹⁶ Gambetta Tessini et al¹⁷ attributed increased responsiveness, sympathy, and supportive attitude towards patients in women to an increased level of stress. According to Farokh-Gisour¹⁸, female respondents demonstrated a higher level of stress in comparison to males, except during the placement of the rubber dam and crown preparation. The most challenging aspect of treating children in this study were physical strain (75%) and behavior management problems (60.7%). Crying (60%) and temper tantrums (60%), followed by stubbornness contributed to moderate stress among the participants. Pediatric dentists experience stress due to the non-cooperative behavior of a child as they have to work faster and remain focused. This might be attributed to the fact that children possess a short attention span, dental fear, and anxiety.^11,14,19 Ayers et al⁹ observed that treatment of children is a common stressor among dentists as pediatric patients often panic and are resistant to dental treatment. Parental attitude (42.9%) and time management (28.6%) constituted the other causes of stress among the respondents. In the present study, local anesthesia administration (68%), followed by cavity preparation (66.7%), and tooth extraction (50%) were ascribed as the most challenging aspects of treatment in a pediatric patient. Local anesthetic administration to an anxious child is regarded as the most stressful procedure among pediatric dentists, general practitioners, and specialists in other fields.²⁰ According to Farokh-Gisour¹⁸ mandibular anesthesia in an anxious child was the most stressful part of the pediatric dental practice due to the special anatomy of the mandible and lack of the child’s cooperation in opening the mouth completely due to fear and anxiety. Rasmussen et al²¹ observed that mandibular block anesthesia in preschool children was perceived as the most stressful pain control method. Ronneberg et al¹⁴ reported dental restoration of children in the age group of 3–5 years as the most rigorous work of dentistry. Farokh-Gisour¹⁸ elicited that preparation of the cavity for mandibular tooth amalgam restoration is the least stressful and it has been attributed to the direct vision and easy access; furthermore, stress induced during the maxillary dental extractions was more in comparison to the mandibular teeth extraction due to decreased access. Behavior management problems in children, the suppositions, attitude of accompanying parents, and the need to be cost-effective can be stressful for dentists in daily dental practice. About 30% of the respondents in the present study had stopped the treatment midway for a child due to stress (50%) followed by non-cooperative behavior (38.9%), parental interference (38.9%), fatigue (33.3%), and procedural error (22.2%).

The present study has certain limitations such as a small sample size, restriction to a single city, and the inability of a cross-sectional study to establish a cause-effect relationship.

Conclusion

Experience and training are instrumental in the stress observed by pediatric dentists during clinical procedures. Promotion of training and reorganization into larger practices may positively influence pediatric dentists’ knowledge, attitude, and management of procedural pain in children. Furthermore, identification and appropriate management of job-related stressors would be crucial in improving the performance, satisfaction, and personal health of pediatric dentists.

Conflict of Interest

None