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Occupational stress is pervasive in dentistry, affecting dental students and emerging and experienced practitioners.1,2 The demanding nature of dental practice, characterized by intricate procedures, high patient expectations, and the continuous pursuit of clinical excellence, often gives rise to a combination of stressors that impact the daily well-being of dental professionals.2 Understanding the origins and manifestations of occupational stress is imperative for devising effective strategies to mitigate its effects and foster a healthier work environment in dental offices and throughout the dental community.3
The significance of addressing occupational stress in dentistry extends beyond individual well-being, profoundly influencing patient care, professional satisfaction, and the long-term sustainability of dental practice. Chronic stress among dental professionals increases predisposition to mental health challenges, including burnout, depression, anxiety, decreased job performance, lower quality of life, and even attrition from the profession.3-6 Moreover, the unique challenges dental practitioners face, such as prolonged periods of concentration and patient anxiety, highlight the need for interventions to reduce stressors and enhance resilience in the profession.5
This article summarizes the existing literature on occupational stress reduction in dentistry and reviews general solutions to the specific challenges of dental practice. It provides practical resources for dental practitioners, educators, and policymakers, offering insights that can be integrated into daily practice. The article explores specific stress triggers, followed by pragmatic solutions designed to tackle the unique challenges faced within dental practice, including integrating mindfulness and cultivating effective work environments.
Vicarious Trauma, Boundaries, Expectations, and Communication
Vicarious trauma, also known as compassion fatigue, presents a seldom-explored stress factor within dentistry. This phenomenon revolves around the impact of patients' anxiety, pain, and discomfort on dental professionals, a subject traditionally studied in the context of physicians, nurses, and social workers dealing with trauma.7 In dental practice, repetitive exposure to patient suffering can contribute to vicarious trauma, potentially resulting in a decline in professional empathy and increasing the risk of burnout.8 In its more severe manifestations, unaddressed vicarious trauma may manifest symptoms akin to post-traumatic stress disorder. Furthermore, prolonged work hours coupled with sleep deprivation can intensify the decline of empathy.9 This circumstance is particularly prevalent among newly graduated dentists and business owners who find themselves immersed in the demands of their professions, often striving to manage every aspect of their practices.3
Additional complexities contributing to stress in dentistry are intertwined with the boundaries, expectations, and communication dynamics among professionals, patients, and staff, with vicarious trauma exerting a negative influence on this triad (Figure 1).8 Maintaining clear, well-defined professional boundaries is crucial for preserving a healthy work-life balance.10 However, unrealistic expectations, whether self-imposed or externally imposed, can erode these boundaries, resulting in prolonged working hours, heightened pressure, and increased stress levels. Breakdowns in effective communication within the dental team and between practitioners and patients can exacerbate misunderstandings, dissatisfaction, and stress. To mitigate these challenges, clear boundaries must be delineated with patients, teams, and families.11 When practitioners are at home, their teams should refrain from non-emergency contact, and similarly, during working hours, practitioners' families should avoid unnecessary interruptions. This approach fosters the concept of being present, enhancing overall productivity. Boundaries with regard to patients should include team members not compromising on taking needed personal rest or meal breaks and avoiding letting the patient dictate treatment decisions. Consequently, any stress reduction strategy implemented in dental practice must address these everyday stressors to ensure lasting and positive outcomes. (These factors are further discussed below in the Work Environment section.)
General Stress Reduction Solutions
There are a number of strategies on which dental professionals can focus in an effort to reduce occupational stress. The following concepts can be integrated into daily practice.
Diaphragmatic Breathing and Mindfulness
Rooted in ancient traditions, mindfulness has emerged as a contemporary stress reduction tool. Mindfulness means paying attention to the present moment without judgment.12 This involves purposefully directing attention to internal mental processes, fostering stress reduction, compassion, and improved communication with patients and staff.13 Embracing a state of mindfulness entails heightened self-regulation, mitigating overreactions and feelings of overwhelm in daily situations, and empowering professionals to navigate challenges adeptly.14,15 Research reveals that mindfulness presents many benefits, encompassing mental, physical, and professional improvement.15 Diaphragmatic breathing is likely the most accessible tool for mindfulness.
Faster and erratic breathing is often present in individuals experiencing stress, depression, and anxiety, with changes in the autonomic nervous system (ANS) response and a lower heart rate variability (HRV). Diaphragmatic breathing slows down respiration rates, reducing ANS activity.16 It involves the diaphragm's contraction, abdominal expansion, and deeper inhalations and exhalations.17
Diaphragmatic slow breathing can initiate the relaxation response.18 Slow breathing (about five to six breaths per minute) can modulate the ANS and improve HRV, which is supported by polyvagal theory.19 Vagal nerves establish bidirectional connections between the brain and body.20 Deep breathing stimulates the vagus nerve, activating the "rest and digest" response. It increases air volume in the lungs and the release of endorphins and lowers cortisol levels. This impacts brain regions that govern emotion regulation, cognitive function, attention, perception, awareness, and decision-making.21 The first systematic review and meta-analysis examining the impact of breathwork on stress supports an association between breathwork and reduced stress levels.18
Breathwork encompasses voluntary changes in the respiration's quality, pattern, and rate.22 The adult respiratory rate ranges between 12 to 18 breaths per minute at rest. The ideal rate is five to six deep breaths per minute with inhalations and exhalations equal in length.23 Five minutes of diaphragmatic breathing can lower anxiety and improve vagal tone.16 In dental practice, the breathwork outlined in Table 1 can be integrated between patient appointments or during breaks for stress reduction.
Work Environment
Fostering an enjoyable workplace environment is paramount, as this directly impacts workers' overall health and well-being. A content team contributes to decreased employee turnover, heightened patient satisfaction, and increased revenue.2,24 Establishing a positive workplace culture is crucial for sustained business success and individual well-being, guarding against detrimental situations like gossip, workplace incivility, passive aggressiveness, and negative behaviors. Daily stressors, particularly interpersonal conflicts involving staff, colleagues, or patients, significantly affect interpersonal dynamics.25 To cultivate a collaborative and supportive team culture, a dental practice should strive for the following objectives:
Shared vision.The initial step in cultivating a positive workplace culture involves articulating a clear vision for all employees. A vision statement is a collective declaration that inspires and guides every team member's daily efforts.25
Relationships. Given the substantial amount of time they spend working together, dentists and staff must foster strong connections. Understanding team members-learning about their interests, families, and hobbies-is essential. Ensuring the team feels regularly seen, validated, and appreciated further strengthens these relationships.26
Communication. Establishing open and transparent communication channels with colleagues, staff members, and patients is pivotal. Ensuring all staff members are well-informed and supported can bolster their sense of value. Providing a conducive environment for expressing thoughts, concerns, and ideas is equally important. Regular team meetings, one-on-one sessions, and team messaging tools (such as Microsoft Teams and Slack) help ensure that everyone stays aligned.
Boundaries. The demanding nature of dental practice often leads to extended working hours and an incessant dedication to patient care. Setting clear limits on working hours, patient load, and personal commitments allows dental professionals to maintain a healthier work-life balance.3 Realistic boundaries with patients, teams, and family prevent burnout and provide time for self-care, relaxation, and rejuvenation.
Expectations. Effective expectation management can help reduce conflicts. Clear communication with patients about treatment plans, potential outcomes, and timelines helps set realistic expectations. Internally, a supportive and communicative work environment is essential in managing staff expectations, ensuring everyone is aligned with their roles and responsibilities.27,28
Staff well-being.Staff well-being should be prioritized through coaching, counseling, ongoing education, and personal development planning. Bonding activities may be implemented to foster team cohesion. Constructive solutions need to be provided to address challenges, and achievements should be celebrated through positive reinforcement.29
Time Management and Workload Distribution
Balancing multiple tasks is an ongoing challenge in dental practice. Through efficient scheduling and adopting suitable technology, it becomes feasible to streamline administrative processes and clinical workflows.30,31 This, in turn, helps achieve a harmonious workload balance and serves as a preventive measure against burnout.
Setting realistic work schedules: patient and staff scheduling. Optimizing patient scheduling is paramount for effective daily clinical management. Block scheduling, where specific time slots are designated for routine appointments, new patient consultations, minor treatments, and significant treatments, helps ensure adequate time is allotted for each dental appointment. The use of practice management software can streamline this approach and aid in preventing scheduling conflicts.32
When generating staff scheduling, it is important to foster flexibility and schedule transparency to cultivate team satisfaction. An effective method involves enabling the staff to exchange shifts, with approval from leadership. Integrating user-friendly software allows the dental team easy access to shift scheduling requests, to which the owner or managing dentist may then consent. This can empower individuals to manage their work schedules, promoting teamwork and a positive work culture.33
Utilizing technology for efficiency.Electronic dental record (EDR) systems form the backbone of a comprehensive apparatus designed to simplify intricate processes, and their usage results in time savings and increased operational efficiency. EDRs can help practitioners meet business and clinical needs to reduce errors and improve the patient experience by handling patient profiles, test results, prescriptions, documents, reporting, and billing, among other applications. A 2017 survey study reported an EDR adoption rate of 52% in the United States.34
Another use of technology to improve efficiency is teledentistry. This modality gained prominence during the COVID-19 pandemic to enhance access to healthcare. It can save time and resources for both patients and clinicians. Teledentistry is a valuable tool for follow-up appointments post-treatment, dental referrals, treatment planning, compliance, and viability.35,36
Finally, the adoption of artificial intelligence (AI) by dental practices can enhance service accessibility and streamline processes, ultimately saving time for both patients and practitioners. AI is pivotal in automating routine tasks such as radiograph analysis, chart compilation, and the cross-referencing of medical and dental histories. Through the use of AI, dentists can save time and energy and thus redirect their focus to patient interactions that enhance patients' overall experience. Furthermore, AI offers valuable and objective second opinion tools, which can help increase patient treatment acceptance and practice profitability.30,37
Continuing Education
As a dynamic field, dentistry demands ongoing learning to navigate new technologies, innovative treatment methods, and evolving healthcare landscapes. Continuous education informs practitioners about the latest advancements, evidence-based practices, and emerging trends. Participating in continuing education enhances clinical skills and instills a sense of professional competence and confidence. Ongoing learning reduces uncertainty-related stress by equipping dentists with the tools to handle complex cases. It fosters a feeling of mastery and professional growth, indirectly contributing to stress resilience.5
Supporting skill enhancement within dental teams is crucial for stress mitigation. Training programs, workshops, and collaborative learning opportunities allow teams to refine their competencies and stay abreast of industry advancements. A culture that furthers skill development promotes a positive work environment, encouraging mutual support. When team members witness individual and collective growth, the shared sense of accomplishment becomes a buffer against stressors.38 In addition to skill development, continuing education courses should include self-improvement and mental wellness training for clinicians.
Mentoring
Mentoring provides a structured support system that allows dentists, particularly those early in their careers, to benefit from the experiences and insights of seasoned professionals. Mentors can offer guidance on clinical decision-making, practice management, and personal development, creating camaraderie and reducing the isolation often experienced in the dental profession.39,40 Mentoring can provide emotional support and a safe space for dentists to discuss challenges and find solutions. It can foster a positive professional identity, reinforcing a dentist's sense of purpose and accomplishment.41
Although there are different types of mentorship, only a dentist mentor would have an in-depth understanding of the specific mental, emotional, financial, and practical challenges linked with dental practices. A dentist mentor can provide solutions to help deal with vicarious trauma, thus improving boundaries, expectations, and communication for the dentist and his or her team.
More Time for Burnout-Relief Activities
To safeguard against burnout, it is important to incorporate interventions that prioritize spending meaningful time with family and friends, pursuing personal interests and hobbies, and practicing self-care, which encompasses attention to nutrition, obtaining optimal sleep, and engaging in regular exercise. Such interventions can prove instrumental in achieving a harmonious balance between personal and professional life.42 Allocating a day off can be beneficial in mitigating vicarious trauma, which is directly related to weekly working hours; this can thereby foster relief from burnout and facilitate higher quality of life and overall well-being.8
Challenges and Future Directions
While these general stress reduction solutions hold promise, challenges in their implementation may arise, ranging from resistance to adopting new techniques to constraints within varying dental settings. Overcoming such barriers requires a tailored approach that considers the specific challenges for each professional and each dental environment, from private practices to large clinics. Furthermore, integrating technology, including AI, teledentistry, and EDR, offers innovative avenues for improving efficiency and reducing the administrative burden, contributing to a more streamlined and stress-free work environment.25,26
Despite significant technical advancement in dentistry, stress, mental issues, and practitioner well-being are usually overlooked. In the corporate world, executive mentoring is a common practice to help leaders and business owners overcome anxiety and stress. Similar to elite athletes, dentists could benefit from mentoring to enhance their performance and well-being, making it a valuable norm for those aspiring to operate at peak levels in dentistry. By opening the conversation and the general mindset to mentorship, the future of younger dentists can look brighter with higher satisfaction, better work-life balance, and lower overall stress. As the dental field evolves, ongoing research and exploration are crucial to uncovering the most effective stress reduction strategies to help ensure the sustained well-being of dental professionals.3
Conclusion
The high prevalence of mental health issues among dental students and professionals underscores the importance of practical strategies to promote stress resilience. Proposed solutions include diaphragmatic breathing and mindfulness; creating a positive work environment; effective time management and workload distribution, including the use of technologies such as EDR, teledentistry, and AI; continuing education and mentoring; and burnout-relief activities. While the implementation of these solutions can help decrease vicarious trauma and stress, hurdles may present themselves, such as resistance to change or resource constraints, thus emphasizing the need for mentoring and tailored strategies to address specific challenges within diverse dental settings. The authors advocate for the integration of burnout and mental wellness education into the dental school curriculum and emphasize the necessity of making it a mandatory component of yearly continuing education. Future research should focus on exploring the long-term effectiveness of the strategies outlined herein to help ensure the sustained well-being of dental professionals amidst the dynamic and demanding nature of their profession.
About the Authors
Kyle Stanley, DDS
Private Practice, Founder, Light Side Dentistry, Beverly Hills, California
Carla Cruvinel Pontes, PhD, MSc, DDS
Certified Health Coach, Researcher, Mouth-Body Research Institute, Greyton, South Africa
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@conexiant.com.
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