|Year : 2020 | Volume
| Issue : 1 | Page : 9-15
Psychologic stress and burnout among dental staff: A cross-sectional survey
Abdullah Mohammed Alzahem1, Yasmeen Abdulhadi Alhaizan2, Latifa Yousef Algudaibi3, Ragad Mohammed Albani2, Abdulrahman Majed Aljuraisi4, Meshal Khaled Alaqeel5
1 King Abdulaziz Medical City, King Saud University, Riyadh, Kingdom of Saudi Arabia
2 College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia
3 College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
4 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
5 King Abdulaziz Medical City, King Saud University; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
|Date of Submission||01-Nov-2019|
|Date of Acceptance||30-Nov-2019|
|Date of Web Publication||30-Dec-2019|
Dr. Latifa Yousef Algudaibi
College of Dentistry, King Saud bin Abdulaziz University, Riyadh
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Backgraound: Professional burnout, a prolonged response to stress, may affect standards of patient care. Burnout is defined as emotional exhaustion (EE), depersonalization, and diminished personal accomplishment (PA).
Aim: The aim of the current study is to identify and compare the psychologic stress and burnout levels among different job titles and specialties in the dental services department. We also examined the effects of marital status, age, and sex on stress and burnout levels.
Settings and Design: A cross-sectional study conducted in the department of dental services at a tertiary medical complex.
Materials and Methods: A convenient sampling approach was used to distribute the questionnaire in the dental services department (n = 177, response rate = 88.5%). Two-validated questionnaires, the Psychological Stress Measure-9, and Maslach Burnout Inventory–Human Services Survey, were used.
Statistical Analysis: SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used for data analysis. P<0.05 was considered statically significant.
Results: The mean (± standard deviation) stress level was 32.6 (±11.43), with the highest stress levels seen in consultants and residents (39.17% and 38.33%, respectively). Hygienists and technicians exhibited the highest lack of PA (24.53%), consultants exhibited the highest EE (24.64%), and residents exhibited the highest impersonal response toward patients (26.67%).
Conclusion: Participants with the job title “Consultant” or “Resident” are the most stressed and burnt-out dental personnel. Specialty, sex, age, and marital status were not identified as risk factors for stress and burnout in our study. Stress and burnout should be reduced to maintain standards of patient care.
Keywords: Burnout, dental staff, dentistry, dentists, psychologic stress
|How to cite this article:|
Alzahem AM, Alhaizan YA, Algudaibi LY, Albani RM, Aljuraisi AM, Alaqeel MK. Psychologic stress and burnout among dental staff: A cross-sectional survey. Imam J Appl Sci 2020;5:9-15
|How to cite this URL:|
Alzahem AM, Alhaizan YA, Algudaibi LY, Albani RM, Aljuraisi AM, Alaqeel MK. Psychologic stress and burnout among dental staff: A cross-sectional survey. Imam J Appl Sci [serial online] 2020 [cited 2020 Dec 2];5:9-15. Available from: https://www.e-ijas.org/text.asp?2020/5/1/9/274295
| Introduction|| |
The dental working environment is a stressful environment that is subject to many stressors related to dental procedures, office organization, and interpersonal relationships involving office personnel and patients. Many people have tried to define stress. Lazarus defines stress as “A state of anxiety produced when events and responsibilities exceed one's coping abilities.” Sarafino defines stress as “The circumstance in which transactions lead a person to perceive a discrepancy between the physical or psychological demands of a situation and the resources of his or her biological, psychological, or social systems.” Stress can be defined as a stimulus (a “stressor”), a response (the effect of stress), or a combination of the two. A stressor is any type of stimulus that a person recognizes as a threat. It could be psychosocial, physical, or psychologic. Psychologic stressors are threats related to a person's internal responses: feelings, concerns, and thoughts about the perceived threat. Psychologic stress occurs when environmental demands exceed an individual's adaptive capacity.
Burnout is a prolonged response to chronic emotional and interpersonal stressors at work and is defined by three dimensions: exhaustion, cynicism, and inefficacy. It was first identified by Maslach in the 1970s as an issue arising among professionals working in human services, and it was defined as “work-related mental and emotional exhaustion (EE) which may be associated with several physical symptoms.” Today, the health-care system is rushed and stressful. Stress may have negative effects on the mental and physical health of health-care providers, which may in turn affect standards of patient care. Studies have identified diverse causes of stress among health-care providers, including different working hours; night shifts leading to lack of sleep; less control over the workplace and minimal autonomy; feelings of isolation; heavy workload; and an imbalance between work and personal life.
A study conducted in Nigeria found that 92.8% of health-care workers felt stressed at work, and that this was due to lack of equipment (30.8%), poor working environment, poor managerial support and poor staff attitude (29.8%), and work overload, emergencies, and ad hoc duties (3.5%). They also reported that the stress resulted in headaches (67.3%), poor concentration (11.6%), and loss of interest in work (10.1%). A study conducted in Saudi Arabia showed that the overall prevalence of stress among health-care workers was 66.2%. In another study conducted in Mexico, high stress levels were reported by 85.5% and low stress levels were reported by 14.5% of 256 dentist participants. Age between 40 and 49 years, female sex, and marital status were identified as risk factors for stress in their study. Finally, another study showed that, in general, dentists who worked in academic institutions were less burnt out than nonacademic dentists.
Many studies have focused on stress among students or undergraduates, but only a few have examined stress among health-care providers. The welfare of this group of workers is an important concern; thus, our study was designed to identify psychologic stress and burnout among health-care providers, compare psychologic stress and burnout between different job titles and dental specialties, and examine the effect of age, sex, and marital status on stress and burnout among health-care providers.
| Materials and Methods|| |
Study area and participants
The study was conducted in the department of dental services at a tertiary medical complex. The participants of the study were dentists (consultants, residents, and interns), dental assistants, lab technicians, and hygienists.
Study design and sampling
We conducted a cross-sectional study based on two validated questionnaires. The study required a minimum sample size of 169 participants to estimate the prevalence of psychologic stress and burnout with a corresponding 95% confidence interval and 5% margin of error. The sample was conveniently chosen from the dental department. Two hundred questionnaires were distributed; 177 participants completed the questionnaire resulting in a response rate of 88.5%.
The data collection sheet consisted of three sections: Section I collected personal and sociodemographic data on the participants, such as their job title, specialty, sex, age, marital status, and years of experience. In Section II, the Psychological Stress Measure-9 (PSM-9) was used to investigate psychologic stress. The PSM was established to assess stress levels in the nonclinical population. Originally, it was a 49-item questionnaire; shorter versions were developed in response to research requirements. The nine-item version is used for general studies of health and well-being in the workplace. The PSM-9 has comparable psychometric features to the original PSM, attaining reliabilities as high as 0.89. The items use statements that manifest affective, cognitive, behavioral, and somatic indices of the psychologic status of being stressed. An eight-point Likert-type scale ranging from 1 (“Not at all”) to 8 (“Extremely”) is used, and participants assess the degree to which they experience each symptom. The last section consisted of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) to measure burnout among the participants. The MBI-HSS was principally evolved to assess burnout among health-care providers in the workplace. It consists of 22 items: EE is assessed by nine items, depersonalization (DP) is assessed by five items, and personal accomplishment (PA) is assessed by eight items. EE is characterized by a state of physical and emotional fatigue. DP is defined as a negative, heartless, and separate attitude that spreads through all sectors of work. PA includes aspects of self-assessment and expresses a sense of proficiency and productivity. Every item uses a seven-point Likert scale ranging from 0 (“Never experienced such a feeling”) to 6 (“I experience such feelings every day”). Greater scores for the EE and DP subscales denote higher burnout, whereas a greater score for the PA subscale denotes lower burnout.
The data collection process started after the study gained institutional review board approval and lasted for 1 week. A questionnaire was distributed to all health-care providers: dentists, dental assistants, and auxiliary staff working in dental services. All health-care providers who were working at the time of data collection were asked to complete the study questionnaires. The research objectives and proposal were explained to the participants, and each participant provided informed consent before filling in the questionnaires.
The raw data were processed in accordance with best practices for raw data management to identify erroneous entries. Quantitative variables were checked for extremely large or small entries corresponding to the units of measurement. Categorical variables also underwent scrutinization to identify entry errors. Erroneous entries were flagged and appropriately treated before analysis. Data cleaning and formatting were performed using Excel® (Microsoft Corp., Redmond, WA, USA), and SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used for data analysis. All variables were summarized using descriptive statistics or frequency tables and percentages. Pearson's Chi-squared test was used to analyze the associations between the three components of the MBI-HSS survey (EE, DP, and PA) and categorical variables such as job title, specialty, sex, age, marital status, and years of experience. Fisher's exact test was used to analyze the associations of EE and PA with dental specialty because of the low expected frequency in each specialty. Means and standard deviation (SD) were used to summarize psychologic stress for variables such as specialty, sex, and marital status. The significance of the variation in psychologic stress for the different variables was assessed using the t-test and analysis of variance. P < 0.05 was considered statically significant. The internal consistency of the questionnaire was also determined using Cronbach's alpha.
| Results|| |
As shown in [Table 1], the percentages of male and female participants were roughly equal (47.67% and 52.32%, respectively), as were the percentages of single and married individuals (47.12% and 52.87%, respectively). The majority of the participants ranged in age from 25 to 34 years (36.41%) and 35–44 years (32.94%). Dental assistants and hygienists and technicians accounted for greater proportions of the participants (25.42% and 25.98%, respectively) than other job titles because they were performing more jobs.
|Table 1: Sociodemographic and personal characteristics of the study participants (n=177)|
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Psychologic stress measure-9
The mean (±SD) stress level of the dental personnel was 32.6 (±11.43), as shown in [Table 2]. Regarding job titles, consultants and residents exhibited greater stress levels than other job titles, with mean (±SD) total PSM-9 scores of 39.17 (±12.53) and 38.33 (±11.1), respectively. Conversely, the least stressed individuals were interns 31.88 (±9.53), dental assistants 29.33 (±11.53), and hygienists and technicians 28.2 (±8.25; P < 0.0001). As this P value was statistically significant, a post hoc test was performed to identify the significantly different groups. There was no significant difference between the results of consultants and residents. However, both were significantly different from the other groups. There were no significant differences (P > 0.05) between different specialties, sexes, age groups, marital statuses, and years of experience.
|Table 2: Psychological stress measure-9 sum score means (and standard deviation) of sociodemographic characteristics|
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Maslach burnout inventory-Human services survey
The MBI-HSS assessed the three dimensions of burnout: PA, EE, and DP. The participants fell into one of three categories in each dimension (high, moderate, or low) depending on their responses [Table 3]. In this study, the value of Cronbach's alpha was 0.78 for PA, 0.86 for EE, and 0.65 for DP. The following results are shown in [Table 4].
|Table 3: Levels of burnout components among health-care providers in the department of dental services, MNGHA (n=177)|
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|Table 4: Association between burnout components and sociodemographic characteristics|
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When comparing job titles according to PA scores, hygienists and technicians had the highest frequency (24.53) in the high PA category, followed by consultants and dental assistants with equal frequencies (20.75), and then residents and interns with equal frequencies (16.98). In contrast, dental assistants had the highest frequency (38.33) in the low PA category, followed by hygienists and technicians (26.67), consultants (18.33), interns, and residents (6.67; P = 0.489).
Regarding dental specialties, conservative dentistry and oral and maxillofacial surgery (OMFS) had the highest frequencies in the high PA category, with equal frequencies (21.74). Conversely, conservative dentistry and preventive dentistry had the highest frequencies in the low PA category, with equal frequencies (26.32; P = 0.7235).
Men were more numerous (60) than women (40) in the high PA category, whereas women were more numerous (66.67) than men (33.33) in the low PA category (P = 0.0152).
Participants in the age group 25–34 years had the highest frequency (40.38) in the high PA category, followed by participants in the age groups 35–44 years (26.92), ≤24 years (17.31), and ≥45 years (15.38). In the low PA category, participants in the age group 35–44 years had the highest frequency (44.07), followed by participants in the age groups 25–34 years (27.12), ≥45 years (20.34), and ≤24 years (8.47; P = 0.2174).
Married participants were more numerous (51.92 and 56.9) than single participants (48.08 and 43.1) in the high and low PA categories, respectively (P = 0.8643).
Participants with <4 years of experience had the highest frequency (41.51) in the high PA category, followed by participants with 4–11 years of experience (33.96) and ≥12 years of experience (24.53). In the low PA category, participants with ≥12 years of experience had the highest frequency (37.29), followed by participants with 4–11 years of experience (35.59) and <4 years of experience (27.12; P = 0.4562).
Consultants were most numerous (24.64) in the high EE category, followed by dental assistants (23.19), and then residents, interns, and hygienists and technicians, with equal frequencies (17.39). However, dental assistants had the highest frequency (39.66) in the low EE category, followed by hygienists and technicians (31.03), consultants (13.79), interns (10.34), and residents (5.17; P = 0.0021).
Regarding dental specialties, Conservative Dentistry had the highest frequencies (24.24 and 35.71) in the high and low EE categories, respectively (P = 0.4056).
Women were more numerous (50.75 and 54.39) than men (49.25 and 45.61) in the high and low EE categories, respectively (P = 0.91).
Participants in the age group 35–44 years had the highest frequency (38.24) in the high EE category, followed by participants in the age groups 25–34 years (27.94), ≥45 years (19.12), and ≤24 years (14.71). In the low EE category, participants in the age group 35–44 years had the highest frequency (40), followed by participants in the age groups 25–34 years (38.18), ≥45 years (14.55), and ≤24 years (7.27; P = 0.1032).
Married participants were more numerous (52.94 and 55.36) than single participants (47.06 and 44.64) in the high and low EE categories, respectively (P = 0.9049).
In the high EE category, participants with ≥12 years of experience had the highest frequency (42.03), followed by participants with <4 years of experience (30.43) and 4–11 years of experience (27.54). In the low EE category, participants with 4–11 years of experience had the highest frequency (40.35), followed by participants with <4 years of experience (31.58) and ≥12 years of experience (28.07; P = 0.0897).
Residents were most numerous (26.67) in the high DP category, followed by interns with a frequency of 23.33, then consultants, dental assistants, and hygienists and technicians with equal frequencies (16.67). However, hygienists and technicians had the highest frequency (36.26) in the low DP category, followed by dental assistants (32.97), consultants (13.19), interns (9.89), and residents (7.69; P = 0.0005).
Regarding dental specialties, Conservative Dentistry and Pediatric Dentistry had the highest frequencies in the high DP category, with equal frequencies (28.57), followed by OMFS (21.43), Endodontics (14.29), Preventive Dentistry (7.14), and Orthodontics and Prosthodontics (0). In the low DP category, Preventive Dentistry had the highest frequency (42.86), followed by Orthodontics (21.43), Conservative Dentistry (17.86), Prosthodontics (10.71), Endodontics (7.14), and OMFS and Pediatric Dentistry (both 0; P = 0.0053). However, this significant difference may be due to the fact that some variables (different specialties) were much less frequent than others.
Men were more numerous (70) than women (30) in the high DP category. Conversely, women were more numerous (58.24) than men (41.76) in the low DP category (P = 0.0255).
Participants in the age group 35–44 years had the highest frequency (41.38) in the high DP category, followed by participants in the age groups 25–34 years (27.59), ≤24 years (17.24), and ≥45 years (13.79). In the low DP category, participants in the age groups 25–34 years and 35–44 years had the highest frequencies, with equal frequencies (36.36), followed by participants in the age groups ≥45 years (14.77) and ≤24 years (12.5; P = 0.4923).
The frequencies of married and single participants were equal (50) in the high DP category, whereas married participants had a higher frequency (56.18) than single participant (43.82) in the low DP category (P = 0.8391).
Participants with 4–11 years of experience had the highest frequency (40) in the high DP category, followed by participants with ≥12 years of experience (33.33) and <4 years of experience (26.67). In the low DP category, participants with <4 years of experience had the highest frequency (37.78), followed by participants with 4–11 years of experience (34.44) and ≥12 years of experience (27.78; P = 0.4333).
| Discussion|| |
In this study, we aimed to investigate psychologic stress and burnout among dental staff. To achieve this, we compared psychologic stress levels and burnout between different dental specialties and professions. We also compared the effects of factors such as age, sex, years of experience, and marital status on psychologic stress and burnout. Stress should be considered a serious issue that affects health. Many studies have linked stress to physical disorders such as cardiovascular disease and psychologic disorders such as anxiety. In this study, we showed that dental consultants and residents are under the most stress. There was no difference in stress levels between consultants and residents, irrespective of their specialty. In contrast, a study with a limited number of participants (36 dental residents) performed in Switzerland reported that they had low-stress levels. In previous studies, however, it has been shown that dentists are more susceptible to high-stress levels than many other health-care professions. In the United Kingdom, 68.4% of dentists surveyed were suffering from stress. Furthermore, in Denmark, 59.7% of dentists reported that they were stressed. Furthermore, in Iran, 58.9% of dentists surveyed were experiencing stress.
In Iran, the most common causative factors for stress among dentists were the high concentration required in and long-term pressure of their work. Conversely, in New Zealand, the most common causative factors for stress among dentists were treating uncooperative children, followed by time pressure related to their career, and then the high concentration level required at clinics. In the United Kingdom, the causative factors resembled those of New Zealand. Dental staff in all three countries reported a common source of stress: time pressure. This source of stress is related to time management. In this study, we showed that the least stressed dental professionals were technicians. We also demonstrated that factors such as age, sex, marital status, and years of experience had no significant effect on the stress level. Our finding of no difference between the stress levels of men and women is similar to that of a study conducted in Yemen, in which they found no differences in stress levels between the sexes. Furthermore, in Iran, there were no significant differences between the stress levels of men and women. In contrast, it has been reported that Irish, Mexican, Chinese, and Swiss female dentists are more stressed than their male counterparts.,,, This discrepancy may be cultural; female dentists must support themselves without support from their families.
All health-care providers are prone to burnout. Burnout has negative consequences, such as decreased motivation, energy, and self-esteem. This study focused on burnout and compared its types among all dental staff. Furthermore, it linked burnout to factors such as age, sex, years of experience, and marital status.
This study showed that, among all dental personnel, hygienists and technicians had the greatest scores in PA. However, dental assistants scored the lowest of all dental staff in PA. In a similar study, PA was linked to salary. We found that men were more numerous in the high PA category, whereas women were more numerous in the low PA category. This result differs from that of a study conducted in Saudi Arabia, which showed the opposite. However, this may have been due to the limitations of their population; they performed their research among dentists only. The age group 25–34 years scored the highest in the high PA category, confirming the findings of a previous study. Dental staff with <4 years of experience were most numerous in the high PA category. Consultants accounted for the highest proportion of the high EE category. In Hong Kong, it was shown that EE is associated with high scores for time- and job-related stressors. However, in this study, dental assistants were most numerous in the low EE category. Female sex and single marital status showed the highest frequencies in both the high and low EE categories. In addition, participants with ≥12 years' experience showed the highest frequency in the high EE category.
Residents had the highest frequency in the high DP category, whereas hygienists and technicians had the highest frequency in the low DP category. In Hong Kong, high DP scores are associated with working in a residential area and related to the low level of education and limited ability to pay for dental treatment of the patients in these regions. Men were most numerous in the high DP category, but women were most numerous in the low DP category. The proportions of married and single individuals were equal in the high DP category.
| Conclusion|| |
As demonstrated in this study, participants with the job title “Consultant” or “Resident” are the most stressed and burnt-out dental personnel. Specialty, sex, age, and marital status were not identified as risk factors for stress and burnout in this study. Being highly stressed and emotionally exhausted, having an impersonal response toward patients, and feeling a lack of accomplishment may affect standards of patient care. To maintain standards of patient care and reduce burnout, psychologic stress should be reduced by the implementation of measures such as stress management programs and raising awareness.
In future studies, the number of participants from each specialty should be increased, which may require the collaboration of multiple dental departments at different hospitals. In addition, other potential risk factors, such as smoking habits or coffee consumption, should also be taken into consideration.
The authors would like to acknowledge King Abdullah International Medical Research Center for the ethical approval and the doctors who participated in the current study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bourassa M, Baylard JF. Stress situations in dental practice. J Can Dent Assoc 1994;60:65-7, 70-1.
Cotton DH. Stress Management: An Integrated Approach to Therapy. New York, USA: Brunner/Mazel; 1990.
Davidson J. 10 Minute Guide: Stress Management. New York, USA: Macmillan USA; 2001.
Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA 2007;298:1685-7.
Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422.
Mészáros V, Adám S, Szabó M, Szigeti R, Urbán R. The bifactor model of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS)--an alternative measurement model of burnout. Stress Health 2014;30:82-8.
Anderson R, Mammen K, Paul P, Pletch A, Pulia K. Using yoga nidra to improve stress in psychiatric nurses in a pilot study. J Altern Complement Med 2017;23:494-5.
Salam A, Abu-Helalah M, Jorissen SL, Niaz K, Mansour A, Al Qarni A. Job stress and job satisfactions among health care professionals. Eur Sci J 2014;10:156-73.
Etim JJ, Bassey PE, Ndep AO, Iyam MA, Nwikekii CN. Work-related stress among healthcare workers in Ugep, Yakurr Local Government Area, Cross River State, Nigeria: a study of sources, effects, and coping strategies. IJPHPP 2015;1:23-34.
Pozos-Radillo BE, Galván-Ramírez ML, Pando M, Carrión Mde L, González GJ. Comparative inter-institutional study of stress among dentists. Acta Odontol Latinoam 2010;23:222-7.
Al-Mobeeriek H, Al-Mobeeriek A. Burnout among dental academics and non-academics in Riyadh and Eastern Province, Saudi Arabia. JPDA 2011;20:199-205.
Lemyre L, Lalande-Markon MP. Psychological Stress Measure (PSM-9): integration of an evidence-based approach to assessment, monitoring, and evaluation of stress in physical therapy practice. Physiother Theory Pract 2009;25:453-62.
Lemyre L, Chair M, Lalande-Markon M. Psychological stress measure (PSM-9): Integration of an evidence-based approach to assessment, monitoring, and evaluation of stress in physical therapy practice. Physiotherapy Theory and Practice 2009;25:453-62.
Myers HL, Myers LB. 'It's difficult being a dentist': stress and health in the general dental practitioner. Br Dent J 2004;197:89-93.
Pouradeli S, Shahravan A, Eskandarizdeh A, Rafie F, Hashemipour MA. Occupational stress and coping behaviours among dentists in Kerman, Iran. Sultan Qaboos Univ Med J 2016;16:e341-6.
Divaris K, Polychronopoulou A, Taoufik K, Katsaros C, Eliades T. Stress and burnout in postgraduate dental education. Eur J Dent Educ 2012;16:35-42.
Moore R, Brødsgaard I. Dentists' perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol 2001;29:73-80.
Ayers KM, Thomson WM, Newton JT, Rich AM. Job stressors of New Zealand dentists and their coping strategies. Occup Med (Lond) 2008;58:275-81.
Cooper CL. Dentists under pressure: A social psychological study. In: Cooper CL, Marshall J, editors. White Collar and Professional Stress. Chichester, UK: John Wiley and Sons; 1980. p. 3-17.
Al-Zubair NM, Al-ak'hali MS, Ghandour IA. Stress among dentists in Yemen. Saudi J Dent Res 2015;6:140-5.
Rogers C, Malone KM. Stress in Irish dentists: Developing effective coping strategies. J Ir Dent Assoc 2009;55:304-7.
Choy HB, Wong MC. Occupational stress and burnout among Hong Kong dentists. Hong Kong Med J 2017;23:480-8.
Pozos-Radillo BE, Preciado-Serrano ML, Acosta-Fernández M, Aguilera-V MÁ, Plascencia-Campos AR. [Predictive psychophysiological stress symptoms in dentists]. Rev Med Inst Mex Seguro Soc 2016;54:151-8.
Kaney S. Sources of stress for orthodontic practitioners. Br J Orthod 1999;26:75-6.
[Table 1], [Table 2], [Table 3], [Table 4]