Open Journal Systems

Received: May 21^st 2014

Accepted: July 16^th 2015

ORIGINAL CONTRIBUTIONS

Predictive psychophysiological stress symptoms in dentists

Blanca Elizabeth Pozos-Radillo,^a María de Lourdes Preciado-Serrano,^a Martín Acosta-Fernández,^a María de los Ángeles Aguilera-V.,^a Ana Rosa Plascencia-Campos^a

^aDepartamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México

Communication with: Blanca Elizabeth Pozos-Radillo

Telephone: (33) 3968 7537

Email: litaemex@yahoo.com.mx

Background: Dentistry has been identified as one of the most stressful occupations in which a dentist’s mental and/or physical health may be affected. The objective of this study was to identify chronic psychophysiological stress symptoms in relation with the presence of high stress levels perceived in dentists at a Social Security institution in Guadalajara, Mexico.

Methods: The design was cross-sectional and analytical by means of a 2011 census consisting of 87 dentists. The Stress Profile and the Stress Symptom Inventory were applied and the analysis was performed with multiple regression.

Results: The perceived stress levels were: high (67.8 %), medium (29.9 %) and low (2.3 %). The most frequent psychophysiological symptom of perceived high level of stress was fatigue with 51 %, and the female gender was the most affected. The existence of a meaningful association was shown between the chronic psychophysiological stress symptoms of insomnia, fatigue and the female gender, and perceived high level stress.

Conclusions: Early identification of the symptoms of chronic stress in dentists would favor the implementation of appropriate preventive programs to care for their health and work place security.

Keywords: Physiological stress; Dentists; Signs and symptoms; Occupational health; Mexico

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Stress faced by dental professionals can not only affect their mental and / or physical health, it can also adversely affect the quality of care of the oral health services they offer. Dentistry has been identified as a stressful occupation due to the combination of difficult work circumstances, because these professionals are often forced to sit for long periods in contorted positions to carry out an extremely intricate and demanding job. ¹ Likewise, dentists may be exposed to potentially dangerous diseases, and unexpected emotional reactions when dealing with nervous or anxious patients. ^2,3 

Stress is conceived of as a normal physiological response of the organism to certain situations, and it can become pathological if the reactions are not appropriate, affecting the person who experiences it physically, emotionally, socially, or psychologically. ⁴

The cognitive-transactional model started with the work of Lazarus and Folkman focused on the assessment made by the person who interacts with their environment to determine the coping mechanisms that they will use to face the perceived threat (real or imagined) of the event, so analyzing some of these aspects may encourage timely assistance to individuals with greater risk.⁵

Evidence suggests that stress, depression, fatigue, anxiety, headaches, carpal tunnel syndrome, neck pain, hypertension, and cardiovascular, musculoskeletal, and skin diseases are common to dentists, as manifestations of their work practice, due to the mentally and physically challenging nature of the profession.^6-11 With respect to gender and stress, studies report women as the most vulnerable group to high levels of stress.^12,13 Given the importance of stress as an occupational hazard, this study aims to identify the symptoms of chronic psychophysiological stress related to the presence of high levels of perceived stress in dentists at a social security institution in the city of Guadalajara, Mexico.

Methods

The design was cross-sectional and analytical. All dentists were surveyed who were found working in a social security institution in the metropolitan area of ​​Guadalajara, Mexico in 2011. Out of 87 dentists, 41.4% were men and 58.6% women. Questionnaires were completed with voluntary participation and under the status of informed consent. The research protocol has the reference number of IISO/CI/06/08 at the Instituto de Investigación en Salud Ocupacional (IISO) of the Universidad de Guadalajara, which adheres to the Declaration of Helsinki of 1975 on ethics in research on human beings and the Ley General de Salud in force in Mexico.  

Instruments

Nowack’s Stress Profile (SP), which assesses levels of perceived stress,¹⁴ consists of two dimensions: one that evaluates ​​reliable, positive, and significant protective resources for health, and the other assessing control before stress risk behaviors, addictions, or negative self-worth. This study only used the items related to the perception of stress; the response options in six points (1 = never, 6 = always), and the indication of the frequency with which stress was experienced during the last three months. The responses were analyzed according to the manual, considering the T-values ​​of the levels: high (T ≥ 60), medium (T 40-59), and low (T ≤ 40). The instrument has already demonstrated homogeneity of variance, with test-retest reliability 0.51 to 0.92 Cronbach's alpha. Factor analyses reported eigenvalues ​​from 0.41 to 0.75 for the scales and confirms its independent structure.¹⁴

The Stress Symptoms Inventory (SSI), validated by Lipp and Guevara,¹⁵ adapted for the Mexican population, has a reported reliability of 0.80 Cronbach alpha.¹³ It consists of 41 items that report characteristic symptoms of chronic stress that people value on a scale from one to six points (1 = never, 6 = always), according to their feelings over the last six months. The frequency of the score is rated as high (5 or 6), medium (3 or 4), and low (1 or 2).

The psychological symptoms of chronic stress are: SE1 (depression), SE4 (outbursts of anger), SE5 (urgent need to run and hide), SE6 (strong need to cry), SE7 (inability to concentrate), SE10 (feeling "tied"), SE11 (nervous tics), SE12 (tendency to panic with small noises), SE13 (nervous laugh), SE14 (stutter), SE17 (anxiety), SE26 (wish to eat at all hours), SE27 (insomnia), SE28 (increased daily dose of tranquilizers), SE29 (increased alcohol intake), SE30 (nightmares), SE31 (increased daily dose of cigarettes), SE32 (proneness to accidents), and SE33 (urgent need to move constantly).

Physical symptoms of chronic stress are: SE2 (pounding heartbeat), SE3 (dry mouth), SE8 (weakness, dizziness), SE9 (fatigue), SE15 (teeth grinding), SE16 (clenched jaw), SE18 (tension headache), SE19 (migraine), SE20 (excessive sweating), SE21 (frequent need to urinate), SE22 (indigestion), SE23 (abdominal pain), SE24 (neck and back pain), SE25 (loss of appetite), SE34 (constipation), SE35 (frequent colds), SE36 (cold hands and feet), SE37 (allergies), SE38 (gastritis), SE39 (colitis), SE40 (hypertension), and SE41 (tremors). In addition, gender was recorded, which was regarded as a predictor variable in the multiple regression.

Analysis

To calculate the association of risk, the odds ratio (OR) was estimated with a confidence interval of 95% (95% CI) and a significance level (p < 0.05). It was applied to each of the psychological symptoms of chronic stress (SSI) with the high level of perceived stress (PS).

Multivariate analysis was made using statistical analysis of logistic regression to control for confounding factors, its disruptive effect, and the estimation of the extent of adjusted association, given the qualitative characteristics of the variables. The method of analysis was stepwise with the high level of perceived stress (PS) and psychological symptoms of chronic stress as predictors, at the previously established level of significance (p < 0.05).

The data were tabulated and processed with SPSS (IBM® SPSS® Statistics 20, USA 1989-2011) with the University license.

Results

In this study, the total of dentists who participated was 87, 51 of whom were women (58.6%) and 36 men (41.4%). Levels of perceived stress were high 59 (67.8%), medium 26 (29.9%), and low 2 (2.3%).  

As for the descriptive analysis of the psychological symptoms and their relationship to gender, the symptom that showed a higher frequency with the highest level of perceived stress and presence "very often" was: anxiety with 50.6% (44). Women were reported as the most affected, with a 23% difference, and the symptoms least frequently found with the high level of perceived stress were: stutter and increased alcohol intake, reported for 5 participants (5.7%) (Annex I).

Annex II shows the descriptive analysis of the physical symptoms and their relationship to gender. The most frequent symptom related to the high level of perceived stress was fatigue with 51.7% (45), and women were the most affected, with a 31% difference; the symptom least frequently found with the high level of perceived stress was grinding teeth, with 5.7% (5).

The analysis of association of the high level of perceived stress with the study variables that were found associated using OR and 95% CI and p < 0.05, were: female gender; psychological symptoms of chronic stress with this level: depression, outbursts of anger, inability to concentrate, nightmares, anxiety, wish to eat at all hours, insomnia, and proneness to accidents; the physical symptoms of chronic stress were: dry mouth, fatigue, tension headache, frequent need to urinate, and neck and back pain (Table I). A binary linear regression analysis was subsequently made, with control of confounders and strength of association by adjusted OR and 95% CI and p < 0.05. It was found that female gender, insomnia, and fatigue maintained their association with the high level of perceived stress (Table II).

The behavior of the study variables relative to the scores obtained with the statistical correlation Pearson’s r. The psychophysiological symptoms of chronic stress (SSI) that showed positive and moderate correlation with perceived stress (PS), (Pearson’s r ≥ 0.30) were insomnia, fatigue, and female gender. Low correlations (r < 0.30) were not considered for this study (Table III).

The correlation coefficients obtained in the stepwise regression analysis for the high level of perceived stress (PS), with each of the psychophysiological symptoms of chronic stress (SSI) that met the criteria of prediction, were: female gender, insomnia, fatigue (R2 = 0.52, F = 10.61, p < 0.05). The symptom of insomnia had the most predictive power (43%) for the high level of perceived stress. Female gender only accounted for 6% of prediction, and the symptom of fatigue when introduced increased prediction by 3%. The regression equation was made as follows (PS) = 0.429 (insomnia) + 0.321 (female gender) + 0.189 (fatigue). The remaining variables, with low or inverse correlation values,​​ were excluded from the model, which significantly increased the percentage explained of the study variable (PS) (Table II).

With regard to assumptions of independence, homoscedasticity, and normality, data did not show multicollinearity with the predictor variables. The average statistical values ​​of "tolerance" for female gender and psychophysiological symptoms of chronic stress stood at 0.99, with no value below 0.96. The proximity of these values ​​to the maximum value (range 0-1) indicated the independence of the contributions of the predictor variables on the values ​​of perceived stress, which determined that the variance of the residuals was constant, with the residuals normally distributed. The average value of VIF = 1.02 with no value below 1.00 showed that there is no problem of collinearity.

Discussion

This study has revealed the existence of a significant association between chronic psychophysiological stress symptoms (insomnia, fatigue) and female gender with a high level of perceived stress. It reported a positive correlation and the regression index indicated a dependence between these symptoms and high levels of perceived stress, that is, when one of them increases, so does the other, in constant proportion. This is the first predictive report to identify psychophysiological symptoms of chronic stress as predictors of a high level of perceived stress in the population of dentists working in a social security institution in Guadalajara, Mexico.

Previous studies on stress in health professionals^16,17 have shown that this occurs during the work of dental health experts, and that dentists are one of the groups of health professionals most likely to be subject to severe stress, the most common symptoms reported are insomnia, fatigue, depression, anxiety, bruxism, headaches (which can lead to failure), substance abuse, and in extreme cases even suicide;^10,18-21 these data are consistent with the results presented here. With regard to stress and gender, studies exist that report that women suffer more stress, depression, panic attacks, and make more suicide attempts than men, which can be explained by the double and triple burden which women are often subject to, results that agree with those presented here.^18,19

The differences between this study and others reported in dentists are because they relate to different variables, and those studies were conducted with students, in other countries, and in different work contexts from the dentists under investigation.^20-25 Our study found that the symptom "anxiety" showed no significant association according to the adjusted OR; it is recommended to pay close attention to this psychic symptom, because it has a high frequency (50.6%). The association between anxiety and stress has already been determined in dentists.

The study has among its strengths that related to the universe of study, which was based on a census. It is also important to note the limitations of this study, which lie mainly in the existence of other factors that could influence the level of perceived stress, such as social, economic, and cultural characteristics that were not considered in this study.

Conclusions

Female dentists with overt symptoms of insomnia and fatigue may present high levels of perceived stress, unlike men.

Stress can cause negative emotional states that favor the appearance of inappropriate behavior, which, in turn, negatively affect the work environment, generating more stress. The exact identification of predictive symptoms of high chronic stress can help recognize and address the welfare of dentists before it affects their occupational health and safety.

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