PERCEIVED STRESS in DENTAL PRACTICE Nada Pop-Jordanova1

PRILOZI, Odd. med. nauki, XXXIV 2, 2013 MANU CONTRIBUTIONS. Sec. Med. Sci., XXXIV 2, 2013 MASA

ISSN 0351-3254 UDC: 616.89-008.441:616.31

PERCEIVED STRESS IN DENTAL PRACTICE

Nada Pop-Jordanova1, Vera Radojkova-Nikolovska2, Silvana Markovska-Simoska1

1 Macedonian Academy of Science and Arts, Skopje, R. Macedonia 2 Faculty of Dentistry, Skopje, R. Macedonia

Corresponding Author: Nada Pop-Jordanova, Macedonian Academy of Sciences and Arts, Bul. Krste Misirkov 2, 1000, Skopje, Tel: + 389 (0)2 3 23 54 00, Fax: + 389 (0)2 3 23 55 00, E-mail: [email protected]

Abstract Stress is a normal physiological response to events that make us feel threatened, or upset our balance in some way. In medicine, it is known that stress, as an emotional state, can be a trigger for many psychosomatic disorders. Work stress and burnout are considered to be serious professional risks in dentistry. The dentist should be aware of these stressors and attempt to manage them in order to avoid becoming occupationally dissatisfied. On the other hand, the other common characteristic of modern life is a growing burden of different chronic diseases. Periodontal disease is one of the two most important oral diseases contributing to the global burden of chronic disease. The aim of this study was to assess the perceived stress in patients with periodontal pathologies, and to compare it with the stress in doctors-dentists and students of dentistry as future professionals. Our study confirmed the presence of significant stress in all three groups of examinees (patients, doctors, and students). Surprisingly, the obtained PSQ scores are similar in the examined groups. In addition, no differences between perceived stress in males and females have been found. There is a minimal positive correlation between age and obtained scores. However, stress must be evaluated as a risk factor both for professionals or for chronic dental patients and some response measures must be undertaken.

Key words: stress, dentists, students, patients.

Introduction prevention for all people, regardless of their Modern life is full of hassles, deadlines, social status. At the same time, the dentist is frustrations and demands. For many people, prestigious, respected and honest. Comparable stress is so common that it has become a way to other professions, dentistry is under public of life. Stress is a normal physiological response pressure. However, work stress and burnout are to events that make us feel threatened, or upset considered to be serious professional risks in our balance in some way. In medicine, it is dentistry. The dentist should be aware of these known that stress, as an emotional state, can be stressors and attempt to manage them in order a trigger for many psychosomatic disorders. In to avoid becoming occupationally dissatisfied. the last decade of the 20th century, stress was a [1–12] topic of high interest in medico-biological rese- On the other hand, the other common arch. characteristic of modern life is a growing bur- The dentist as a specialist enjoys a high den from different chronic diseases. Periodontal degree of professional independence. His fore- disease is one of the two most important oral most social responsibility is to treat patients suf- diseases contributing to the global burden of fering from toothache and to promote oral health chronic disease. [13, 14] 136 Nada Pop-Jordanova, et al.

Periodontal disease is a widespread patho- meet people, and on the other hand, people are logy that affects about 40% of the population, likely to stay away from them, due to the bad especially those over 40 years. Periodontal dise- effects which come with the disease. ase is also known as the 'loose teeth disease'. A study by Wu YM [19] where the perio- The disease starts as an inflammation with ble- dontal status has been evaluated in childbearing eding from the gums and deepened periodontal age women in a region of China accentuated the pockets. Inflammation is not stopped; it spreads need for urgent improvement of oral health. into the bone the teeth are attached to, leading to The aim of this study was to assess the per- bone and dental retracts. Finally, the teeth beco- ceived stress in patients with periodontal patho- me loose and fall out. Normally, this is a slowly logies, and to compare it with the stress in doc- progressive condition, but even after years of tors dentists and students of dentistry as future struggle it ends with toothlessness because of the professionals. disease. In addition to social determinants, periodontal health status is related to several proximal Methodology and sample factors. Modifiable risk factors, such as tobacco The sample comprises three groups of use, excessive alcohol consumption, poor diet examinees: patients with periodontal disease and nutrition, obesity, psychological stress and (N = 40), doctors dentists (N = 48) and stu- insufficient personal/oral hygiene, are important dents in the last year of dentistry (N = 56). and these principal risk factors for periodontal The psychometric instrument we used is disease are shared by other chronic diseases. the Perceived Stress Questionnaire (PSQ). Con- [15–17] sisting of 30 items, the PSQ was developed as Epidemiological findings say that chronic an instrument for assessing stressful life events periodontitis affected about 750 million people and circumstances that tend to trigger or exa- or some 10.8% of the population in 2010. Like cerbate disease symptoms. [20, 21] other conditions intimately related to access to As is well known, a major theme in re- hygiene and basic medical monitoring and care, cent psychosomatic research has been the periodontitis tends to be more common in econo- effect of stress on the course of disease, but mically disadvantaged populations or regions. Its there is no consensus as to how to measure it. occurrence decreases with a higher standard of Researchers have variously concentrated on living. In the Israeli population, individuals of external stressors in the form of life events, or Yemenite, North-African, South Asian, or Medi- chronic difficulties; in addition, they have eva- terranean origin a higher prevalence of periodon- luated subjective components such as anxiety, tal disease is diagnosed than in individuals of depression and psychiatric symptoms. Also, it European descent. Paradentosis is really dange- is very important to not under-recognize the rous. It may be inevitable and some people can cumulative minor stressors or "hassles" of eve- have it when they grow older, around 30–40 ryday life and the individual sense of control or years of age. There are cases when even children coping. or adults who are still young have a case of perio- The PSQ was developed and validated by dontal disease (another name for paradentosis). a group of researchers involved in psychosomatic Paradentosis may have really detrimental effects. medicine (psychologists and doctors in internal It can also be dangerous as it affects not only the medicine) for evaluating the relationship between dental health, but the physical health too. Many stress and illness. As a result, a 30-items que- epidemiological studies have indicated that perio- stionnaire has been developed. Factor analysis dontitis is an important risk factor for coronary for PSQ yielded seven factors, of which those heart disease. [18] reflecting interpersonal conflict and tension were Patients suffering from periodontitis will significantly associated with health outcome. experience bad breath and ultimately their teeth Factor names were assigned appropriate to the might become so damaged that there is no other contributing items: harassment, overload, irrita- choice than having them replaced by dentures. bility, lack of joy, fatigue, worries, and tension. Periodontal disease is very likely to affect one’s In this context, PSQ is thought to be a valuable personal life greatly; patient will be ashamed to instrument in psychosomatic research. Perceived stress in dental practice 137

Results and discussion that a similar perceived stress is present in both The sample of patients consisted of 18 patients with chronic disease and in professio- males and 22 women with periodontal patho- nals. logies (total number N = 40). The mean age for The original article concerning to PSQ males was 45.8 years (SD 16.2); youngest [20] described that generally, for males the PSQ patient was 22 and the oldest one 71. The mean mean score was 0.40 and for females 0.43. The age of female patients was 42.3 years (SD highest scores were obtained in hospitalized 14.4); the youngest was 24 and the oldest 77. patients with some psychosomatic disorder (such The sample of doctors / dentists consisted as ulcerative colitis). Scores on the PSQ were of 40 females and 8 males (total number N = 48). associated with stressful life events. But since The mean age for males was 41.8 years (SD 7.3). any pathogenic potential lies not in the stressor For females, the mean age was 40. 6 years (SD event but in the stress emerging from its inte- 6.8); the youngest was 28 and the oldest 54. raction with the individual, the attempt to study The sample of students comprised a total stress-illness links by looking for preceding life number of N = 49 examinees. There were 37 fe- events has built-in limits. On the other hand, males, with a mean age of 22. 8 years (SD 1.9) some stress-related disease can be missed by and 19 males, mean age 22.9 years (SD 2.3). investigating life events alone. However, PSQ Table 1 summarizes age-related characteristics of is frankly subjective. It is intended to maximize the samples. sensitivity to ongoing stress and to make the PSQ more useful for prospective studies of Table l organic disease, or in cross-sectional investiga-

Age of examined samples tions whose dependent variable is beyond patient awareness. In our study, mean values in Mean age patients obtained for PSQ was 0.45 for males Sample (years) SD and 0.48 for females, which is comparable with Patients males 45.8 16.2 the original findings [20, 21]. females 42.3 14.4 It is interesting that the obtained scores Doctors males 41.8 7.3 for PSQ for doctors is highest: for males PSQ females 40.6 6.8 mean value is 0.58; for females 0.51, which re- Students males 22.9 2.3 present an important level of stress. Concerning females 22.8 1.9 students of dentistry, obtained scores for PSQ N = 144 were 0.41 for females and 0.52 for males. Both results (for doctors and students) are higher for PSQ scores obtained for all three groups males than for females. It could be interpreted of examinees is presented on Fig. 1. that females are more resistant to everyday stressors. In addition, we calculated the variance of obtained scores from the three groups of examinees with factor ANOVA. We did not find any statistically significant difference.

Figure 1 – Obtained PSQ for examined groups

Statistics show that there is no significant difference between obtained PSQ scores for pa- Figure 2 – Difference between PSQ scores tients, doctors and students (p = 0.69). It means in samples (p = 0.69) 138 Nada Pop-Jordanova, et al.

Concerning the gender, we obtained similar results. There is no significant difference in PSQ scores between men and women. (Fig. 3)

Figure 6 – Correlation between PSQ scores and examined groups

The obtained negative correlation between Figure 3 – Obtained PSQ scores in females PSQ scores and three groups of examinees is and males (p = 0.95) shown in Fig. 6. The development of periodontal inflam- Factor ANOVA calculated for gender vari- mation is a complex process; therefore animal ance shows a minimal statistical significance (p models have been developed to assist in its = 0.02) (Fig. 4) understanding. The main etiological factor of

periodontal disease is bacterial plaque, but the pathogenesis of the disease is affected by envi- ronmental factors that modify or induce syste- mic progression, such as stress. In a study by Riviera C. et al. [16] the aim was to examine the effect of chronic restraint stress (RS) on the severity of experimental periodontal disease in rats. The results of the study showed that RS modulates periodontal inflammation and that the rat model described herein is suitable for

investigating the association between stress and Figure 4 – ANOVA for age-related PSQ scores periodontal disease. Human studies suggest that It was interesting to calculate the cor- negative life events and psychological factors relation between age and obtained PSQ scores may contribute to an increased susceptibility to (Fig. 5). The minimal positive correlation (p = periodontal disease. It has been reported that 0.011) was obtained. This means that with age stress produces neuroendocrine changes and a slow rise in perceived stress is confirmed. certain adverse effects on the immune system, which affect the inflammatory response on periodontal tissues. The cortisol-awakening response (CAR) is a distinct facet of the circadian cortisol rhythm associated with various health conditions and risk factors. It has repeatedly been suggested that the CAR could be a result of the anticipated demands of the upcoming day (stress anticipation) and could support coping with daily life stress. Findings indicate that the CAR increase is associated with successful coping with same-day daily life stress. [17] Figure 5 – Correlation between age In addition to periodontosis, recurrent and obtained PSQ scores aphthous ulcers (RAU) are one of the most Perceived stress in dental practice 139 common and poorly understood mucosal disor- a positive approach in the form of a health model ders. Most of the literature suggests that stress focussed on what is right with people, such as has a causal role in RAU and it is estimated feelings of well-being and satisfaction. Higher that at least 1 in 5 individuals is afflicted with self-rated emotional intelligence was signifi- RAU. Review of the literature reveals that cantly associated with less burnout (p < 0.001) nutritional and stress factors may be of para- and higher job satisfaction (p < 0.001). Higher mount importance in the occurrence and seve- patient satisfaction was correlated with less rity of RAU. In the study by Handa R. [23] it burnout (p < 0.01). Less burnout was found to was shown that stress emerged as having a be associated with higher job satisfaction (p < causal role on RAU, along with haematinic 0.001). [24–26] deficiencies and poor nutritional status in pro- While stress is pervasive in the world fessional undergraduate college students. today, and particularly in the dental surgery, In our study we did not show that per- coping strategies can counteract it. In the paper ceived stress is such an important factor in pa- by Mazzey [11] the personality features of the tients with periodonthal pathologies. It is sur- hardy dentist are discussed. The fact that stress prising that the level of stress was higher in pro- and its effects depend largely on individual fessionals than in patients. perception of stressors; five habits to develop Clinical and public health research data for stress reduction could be: seeking infor- have shown that a number of individual, pro- mation, taking direct action, inhibiting action, fessional and community health measures may engaging intrapsychic efforts and calling on be valuable in preventing the major oral dise- others. ases. The fundamental gap in knowledge, however, is not confined to 'what to do' but rather Conclusion 'how' to translate the scientific findings into Our study confirmed the presence of stress effective and sustainable programmes for groups in all three groups of examinees (patients, doctors and populations. Community interventions and and students). The obtained PSQ scores are si- delivery of preventive oral care by oral health milar in the examined groups. services may have positive outcomes for perio- In addition, no differences between per- dontal health but periodontal research needs to be ceived stress in males and females have been further strengthened by the provision of sound found. evidence. It is somewhat remarkable that rese- There is a minimal positive correlation arch on true population-directed actions in the between age and obtained scores. prevention of periodontal disease is most unu- However, stress must be evaluated as a sual. risk factor either for professionals or for chronic In the prevention of periodontal disease, dental patients and some response measures use of probiotics is suggested. Probiotics are must be undertaken. dietary supplements containing potentially beneficial bacteria or yeasts. 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