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 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 66-71

Comparison of stress, burnout and its association among postgraduate orthodontic and undergraduate students in India

1 Department of Orthodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Orthodontics, Sibar Dental College and Hospital, Takkellapadu, Guntur, Andhra Pradesh, India

Date of Web Publication8-Jun-2018

Correspondence Address:
Prasad Mandava
Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, Narayana Dental College and Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_127_17

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Aim and Objectives: Stress and burnout are the wave of the present decade and dentists and dental specialists are found repeatedly on top of the charts of the more stressed occupation; however, the prevalence among orthodontic postgraduates in India has not been well researched. The present study aimed to investigate the stress and burnout levels of postgraduate students of orthodontics in India. Materials and Methods: A descriptive, cross-sectional study was conducted to evaluate stress and burnout in postgraduate students of orthodontics in India. A stratified randomized sampling method, with stratification as North, East, West, South, and central population was employed. A questionnaire format formulated by the International Stress Management Association, including Maslach burnout inventory was filled by each of these individuals. Results: A total of 284 individuals showed significance for stress and personal accomplishment (PA) (P < 0.05) whereas statistically insignificant for genders. There is statistically significance for geographical distribution to depersonalization and PA. The Pearson's correlation is positive for stress and components of burnout in postgraduates and is negative for undergraduates. Conclusion: This study was the first of its kind to explore stress, burnout, and its association among orthodontic postgraduate students and undergraduates in the country. There are significant levels of stress and burnout in both undergraduates and postgraduates. There is a statistically significant positive correlation to the components of burnout found in postgraduates. These findings may help orthodontic community in planning, management, and prevention of stress and burnout.

Keywords: Burn out, depersonalization, emotional exhaustion, Maslach burnout inventory, stress

How to cite this article:
VenkateshNettam, Mandava P, SankarSingaraju G, Ganugapanta VR, Yelchuri H, RevathiPeddu. Comparison of stress, burnout and its association among postgraduate orthodontic and undergraduate students in India. Indian J Dent Sci 2018;10:66-71

How to cite this URL:
VenkateshNettam, Mandava P, SankarSingaraju G, Ganugapanta VR, Yelchuri H, RevathiPeddu. Comparison of stress, burnout and its association among postgraduate orthodontic and undergraduate students in India. Indian J Dent Sci [serial online] 2018 [cited 2019 Feb 16];10:66-71. Available from: http://www.ijds.in/text.asp?2018/10/2/66/233975

  Introduction Top

Most studies in orthodontic literature objective to provide the practitioner with improved understanding of orthodontics and its treatment plan. It is time to spotlight on the state of mind of the orthodontic postgraduates. Just how resilient is today's generation of Orthodontists? Can they cope up with the stresses and strains of patient care or have they become emotionally exhausted depersonalized and burnt out.

Stress is defined as the biological reaction to any adverse internal or external stimulus, physical, mental or emotional which tends to disturb the organism's homeostasis.[1] Stress is considered as a two-edged sword that could either stimulate and motivate the students to peak performance or reduce the students to ineffectiveness.[2] Stress is one of the important aspects in dental practice and if allowed to grow unchecked can lead to mental anguish and depression.[3] Stressors due to fear of parents were found more significant in India, to the financial situation of the students were more significant in Western countries than in Eastern countries and to resources and dental material supply were more significant in the developing countries in Africa.[4] Occupational stress among dentists has regularly been the individual of research in the last two decades.[5]

Burnout is a distinct psychological construct. It has a number of features that separate burnout from occupational stress. Burnout differs from stress in which it requires consistent pressures to be brought to bear on the individual. A state of emotional, physical, and mental tiredness as a result of work conditions.[6] Maslach and Jackson [7] stated burnout as a syndrome of emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). The three dimensions of the burnout are not equivalent, but refer to three distinct aspects of the syndrome. EE refers to feelings of being depleted of one's emotional resources, depersonalization refers to a negative, callous, or excessively detached response to the recipients of one's services or care, while reduced PA refers to a decline in one's feelings of competence and less successful achievement in one's work.[7]

Occupational stress and burnout in students attending orthodontic specialty has not been studied thoroughly. A few studies describing stressful aspects of dentistry have reported a number of specialists responding to the survey, but none of these reports a separate analysis of the specialist's responses. The stressors in orthodontic practice are similar to those in dentistry, but some stressors unique to the orthodontic profession do exist.[8]

Research on burnout among students always serves a scientific goal since it provides information on the prevalence of burnout and associated factors. However, research on burnout also serves another goal, namely, to provide information for prevention.[5] The purpose of the present study is to evaluate stress and burnout and its association among undergraduates and postgraduates. Hypothesis of this study was postgraduate students has more stress and burnout levels.

  Materials and Methods Top

A descriptive, cross-sectional, and comparative study was conducted to evaluate stress and burnout in undergraduate and orthodontic postgraduate students of India.

A pilot study was conducted on a sample of postgraduate students of orthodontics and dentofacial orthopedics who have attended the lingual orthodontic course (January 22, 23–2013, Mangalore, India.) to check the feasibility of the methodology planned. Pilot testing assessments were utilized to validate the questionnaire of stress and burnout for the study proper. Cronbach's alpha's analysis was computed as measures of internal consistency. With regard to burnout scales, significant values were observed. The alpha values were 0.91(EE), 0.64 (DP), and 0.84 (PA).

A minimum sample size was estimated to be 133 based on the pilot study. In view of the design of this study, the sample was selected by a stratified randomized sampling method, with stratification as North, East, West, South, and central population. Sample size determined on the basis of a pre-assigned significance level of 95% and power of 80%.

Recruitment of study participants was carried out in postgraduate students of orthodontics and dentofacial orthopedics who attended 19 IOS PG STUDENTS CONVENTION-2015, Bengaluru, India. The clinical undergraduate students from different dental colleges throughout the India were included in the study as comparison group.

Questionnaire for stress was derived from International Stress Management Association, the questionnaire comprised 25 questions with dichotomous (YES/NO) options, scored as “1” for YES and “0” for NO. Based on total score obtained, sample is divided into three groups as - ≤4-least likely, 5–13-more likely, and ≥14-most prone.

Maslach burnout inventory, as in the investigation by Gorter et al.[5] will be used in the study. Burnout will be measured using the three dimensions of the 22 item.

  • EE; seven items
  • DP; seven items
  • PA; eight items.

The items were ranked by respondents according to their reported frequency on a seven-point Likert scale, where 0 - never, 1 - a few times a year, 2 - monthly, 3 - a few times a month, 4 - weekly, 5 - a few times a week, and 6 - every day.

Scoring results

The interpretation of scoring for burnout is shown in [Table 1]. A high score in the first two sections and a low score in the last section may indicate burnout. Additional sociodemographic variables were also collected in the survey questionnaire. Participant responses <80% questions were excluded from the study. The questionnaire was given to both postgraduate and undergraduate and evaluated separately. Only one examiner (N V) involved in data collection, data analysis, and evaluation.
Table 1: Scoring interpretations for components of burnout

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Data analysis

Statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) 21 version IBM, USA. Basic demographic data were expressed in percentages. Mean scores were calculated for respective domains. Statistical tests ANOVA, unpaired t-test was done to find out the significance of results. Pearson's correlation was done. The level of significance was set at P < 0.05 for all tests. Kappa statistics was performed for intraexaminer reliability.

  Results Top

A total of 284 (51%male and 49% female) postgraduate (50%) and undergraduate (50%) students were given questionnaires by hand, of which 165 questionnaires received back. The participants who did not answer more than 20% of questions were excluded and the final study sample for statistical analysis obtained was 142 thus accounting to a response rate of 71%. For the final selected sample, the questions which were not answered were recorded by their mean score. The undergraduate sample (comparison group) was collected by mailed questionnaires, and same methodology was followed as mentioned above to equalize the sample in all variables as study sample. The frequency of distribution is shown in [Figure 1]. Analysis of the data revealed that the mean age of the postgraduates and undergraduates were 26.16 ± 2, 20.98 ± 1.14. The mean of stress is analogously expressed and was not statistically significant (P > 0.05) for gender and geographical distribution in relation to stress in both postgraduates and undergraduates [Table 2]. The means score of participants for EE, DP, and PA are shown in [Table 3]. The mean values of EE were equally noted and are not statistically significant (P > 0.05) for both gender and geographical distribution in postgraduate and undergraduate sample [Table 3]. The mean values of DP is quantified similar for gender, unlike it is high in East India with statistical significance (P < 0.05) for geographical distribution in relation for postgraduates [Table 3]. The mean values of DP are similarly expressed for gender and are high in Central India with statistical significance (P < 0.05) for geographical distribution for undergraduates [Table 3]. The mean values of PA are comparatively in the same range for both the genders. It is found to be low in South Indian students which are statistically significant (P < 0.05) in relation to geographical distribution for postgraduates [Table 3]. The mean value of PA is similarly expressed for gender but it is found to be low in East Indian undergraduates (P < 0.05) shown in [Table 3]. The comparative evaluation of stress and burnout in both the undergraduate and postgraduates is shown in [Table 4]. There is statistical significance (P < 0.05) for comparison of stress and PA in postgraduates and undergraduates. Pearson's Correlation analysis was done to investigate the relationship between the stress and burnout. The results showed that there was a significant correlation between stress and burnout components in orthodontic postgraduates. The positive correlation for stress and EE, DP and as well as negative correlation for PA in postgraduates is clearly depicted in the [Figure 2]. However, it was noted that there was no significant correlation between stress and burnout (EE, DP, and PA) components in Undergraduates. The [Figure 2] represents the negative correlation for stress and EE, DP, and PA.
Figure 1: Geographical distribution of professionals

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Table 2: Test of significance for overall comparison of stress among professionals in relation to gender and region wise

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Table 3: Test of significance for overall comparison of burnout among professionals in relation to gender and region wise

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Table 4: Comparison of stress and burnout among postgraduate and undergraduate students

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Figure 2: Correlation of Stress and components of burnout

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  Discussion Top

Cooper et al.[2] reported that the dental profession was the most stressful among all health-care professions. It may be argued that a relation between work stress and burnout is no surprise. Nevertheless, burnout is usually seen as a consequence of occupational stress.[5] According to Murtomaa H et al,[9] burnout begins with a health-care employee experiencing work as stressful which progresses through the experience of stress and fatigue to a defensive stage marked by changes in behavior and attitudes toward patients.

Brake et al.[10] reported that that one in every five active Dutch dentists was at risk of burnout, with one in every eight having high overall levels of burnout. In a German study [11] conducted at the universities of Dresden, Freiburg, and Bern among dental students, 10% had nonnormal values regarding EE, 17% regarding reduced PA and 28% regarding DP.

Our study showed that 57.7% of postgraduates were more prone to stress, 33.1% were showing moderate to high level of EE, 66.9% were in the ranges of moderate to high levels of DP, and only 20% showed high levels of PA. Even though the frequency of high levels of stress and burnout were relatively high in undergraduates than postgraduates but the mean scores were high for postgraduates (P < 0.05).

There are studies in this regard reporting that females perceived more stress than males,[2],[12],[13],[14] while some studies showed that overall males perceived more stress than female,[6],[15] as like of stress there are studies showing that women exhibit less DP compared to men.[16] Prior studies revealed some variation in perceived stressors between males and females,[17],[18],[19],[20],[21],[22] while other studies did not detect any gender differences.[23],[24] Pani et al.[25] used a biomarker (salivary cortisol) to measure dental students' stress and found no gender difference at the baseline and in clinical settings. Similarly, the present study showed no gender variance as regards to stress and burnout levels, and statistical insignificance with unpaired t-test for gender. The insignificant difference could be attributed to the fact that they were living and working in the same environment and facing the same sources and amount of stressors.

Our study demonstrated the different levels of stress between undergraduates and postgraduates (P < 0.05). PA appears to be the main component of burnout phenomenon within both the groups and is also statistically significant with P = 0.05 when both groups are compared. This component seems to be higher in postgraduates compared to undergraduates. However, the results of our present study are in contrast with Al-Zubair NM et al.[26] study which had been conducted with masters or PhD students.

The study also shows that both undergraduates and postgraduates revealed moderate to higher levels of burnout with the mean score levels of burnout being higher in postgraduates. This variation could be due to habituated working environment for enduring period of time that a postgraduate is exposed during course time unlike undergraduates whose working conditions are inconsistent. The features of burnout in undergraduates may be due to those levels of stress which undergraduates are showing or variation in subjective perception during the time of examination.

Pearson's correlation coefficient analysis was carried out to correlate stress and burnout components for postgraduates and undergraduates. It showed a positive correlation for burnout in postgraduates while it was not same in the case of undergraduates. This difference can be attributed to high levels of stress in postgraduates than undergraduates. The present study disclosed a close association of the duration of stress and burnout. Probably, the continuation of stress levels from undergraduate education to post graduation had led to the development of increased burnout levels in postgraduates which are statistically significant (P < 0.05). This is in line with the study of Gorter et al.[27] which concluded that professional burnout is considered a possible long-term consequence of occupational stress.

EE seems to be the second major factor of stress and burnout. However, the difference between the groups is not statistically significant. The present study displayed 7.7% of EE, 35.9% of DP and 50% of reduced PA participants. Humphris et al.[23] had reported a 22% prevalence of EE burnout “cases” among European dental students, this proportion, however, ranged from 3% in Finland to 46% in Germany. Pöhlmann et al.[28] in a study among German and Swiss dental students found that 10% of respondents were “cases” in the domain of EE, 28% in DP, and 17% in reduced PA. Direct relationship between studies cannot be made, because a network of personal, sociocultural factors, curricular, and extracurricular may interact with the respondent's development and expression of burnout symptoms.

Humphris [23] suggested that several ways of burnout can be prevented which include recognition and understanding of the problem, organizing regular breaks from work so that levels of negative experience from burnout are temporarily relieved. Teaching and research may divert and distract the burnout dentist from patient contact. Changing the general attitudes of management and raising their awareness to the possibility of burnout in staff is also vital in prevention and subsequent treatment. Improving working posture and the physical working environment and slowing down the pace of work can prove surprisingly effective in reducing burnout.[9]

The preventive strategies can be at two levels: individual and organizational. At an individual level, it is important to retain cognitive clarity, holding meetings among colleagues to share problems and emotional states, fostering personal balance, and simulating working situations (role play). At an organizational level, preventive strategies are meant to change the working environment of operators and their work-style. It aims at improving organizational culture by stimulating and updating.[2] Support and counseling services are routinely available to medical and dental students; however, these resources appear to be underutilized.[29],[30] It will require concerted efforts of all stakeholders including need assessments,[31] climate studies [32],[33],[34] and qualitative research [35],[36] to identify and implement measures that are required to promote students' personal, academic, and professional well-being.

  Conclusion Top

There are significant levels of stress and burnout in both undergraduates and postgraduates. Statistically significant with a positive correlation to components of burnout found in postgraduates. These findings may help dental community in planning, management, and prevention of stress and burnout.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Rada RE, Johnson-Leong C. Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc 2004;135:788-94.  Back to cited text no. 1
Sugiura G, Shinada K, Kawaguchi Y. Psychological wellbeing and perceptions of stress amongst Japanese dental students. Eur J Dent Educ 2005;9:17-25.  Back to cited text no. 2
Joffe H. Dentistry on the couch. Aust Dent J 1996;41:206-10.  Back to cited text no. 3
Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH. Stress amongst dental students: A systematic review. Eur J Dent Educ 2011;15:8-18.  Back to cited text no. 4
Gorter RC, Albrecht G, Hoogstraten J, Eijkman MA. Work place characteristics, work stress and burnout among Dutch dentists. Eur J Oral Sci 1998;106:999-1005.  Back to cited text no. 5
Kaney S. Sources of stress for orthodontic practitioners. Br J Orthod 1999;26:75-6.  Back to cited text no. 6
Gorter RC, Storm MK, te Brake JH, Kersten HW, Eijkman MA. Outcome of career expectancies and early professional burnout among newly qualified dentists. Int Dent J 2007;57:279-85.  Back to cited text no. 7
Roth SF, Heo G, Varnhagen C, Glover KE, Major PW. Occupational stress among Canadian orthodontists. Angle Orthod 2003;73:43-50.  Back to cited text no. 8
Murtomaa H, Haavio-Mannila E, Kandolin I. Burnout and its causes in Finnish dentists. Community Dent Oral Epidemiol 1990;18:208-12.  Back to cited text no. 9
Brake HT, Gorter R, Hoogstraten J, Eijkman M. Burnout intervention among Dutch dentists: Long-term effects. Eur J Oral Sci 2001;109:380-7.  Back to cited text no. 10
Prinz P, Hertrich K, Hirschfelder U, de Zwaan M. Burnout, depression and depersonalisation-psychological factors and coping strategies in dental and medical students. GMS Z Med Ausbild 2012;29:Doc10.  Back to cited text no. 11
Rajab LD. Perceived sources of stress among dental students at the University of Jordan. J Dent Educ 2001;65:232-4.  Back to cited text no. 12
Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update 1999;26:94-8, 100.  Back to cited text no. 13
Abu-Ghazaleh SB, Rajab LD, Sonbol HN. Psychological stress among dental students at the University of Jordan. J Dent Educ 2011;75:1107-14.  Back to cited text no. 14
Acharya S. Factors affecting stress among Indian dental students. J Dent Educ 2003;67:1140-8.  Back to cited text no. 15
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.  Back to cited text no. 16
Silverstein ST, Kritz-Silverstein D. A longitudinal study of stress in first-year dental students. J Dent Educ 2010;74:836-48.  Back to cited text no. 17
Pau A, Rowland ML, Naidoo S, AbdulKadir R, Makrynika E, Moraru R, et al. Emotional intelligence and perceived stress in dental undergraduates: A multinational survey. J Dent Educ 2007;71:197-204.  Back to cited text no. 18
Polychronopoulou A, Divaris K. Dental student's perceived sources of stress: A multi-country study. J Dent Educ 2009;73:631-9.  Back to cited text no. 19
Polychronopoulou A, Divaris K. A longitudinal study of Greek dental student's perceived sources of stress. J Dent Educ 2010;74:524-30.  Back to cited text no. 20
Sanders AE, Lushington K. Sources of stress for Australian dental students. J Dent Educ 1999;63:688-97.  Back to cited text no. 21
Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and psychological disturbance among dental students in the West Indies. J Dent Educ 2002;66:1021-30.  Back to cited text no. 22
Humphris G, Blinkhorn A, Freeman R, Gorter R, Hoad-Reddick G, Murtomaa H, et al. Psychological stress in undergraduate dental students: Baseline results from seven european dental schools. Eur J Dent Educ 2002;6:22-9.  Back to cited text no. 23
Sofola OO, Jeboda SO. Perceived sources of stress in Nigerian dental students. Eur J Dent Educ 2006;10:20-3.  Back to cited text no. 24
Pani SC, Al Askar AM, Al Mohrij SI, Al Ohali TA. Evaluation of stress in fi nal-year Saudi dental students using salivary cortisol as a biomarker. J Dent Educ 2011;75:377-84.  Back to cited text no. 25
Al-Zubair NM, Al-ak'hali MS, Ghandour IA. Stress among dentists in Yemen. Saudi J Dent Res 2015;6:140-5.  Back to cited text no. 26
Gorter RC, Eijkman MA, Hoogstraten J. Burnout and health among Dutch dentists. Eur J Oral Sci 2000;108:261-7.  Back to cited text no. 27
Pöhlmann K, Jonas I, Ruf S, Harzer W. Stress, burnout and health in the clinical period of dental education. Eur J Dent Educ 2005;9:78-84.  Back to cited text no. 28
Givens JL, Tjia J. Depressed medical student's use of mental health services and barriers to use. Acad Med 2002;77:918-21.  Back to cited text no. 29
Pasnau RO, Stoessel P. Mental health service for medical students. Med Educ 1994;28:33-9.  Back to cited text no. 30
Stecker T. Well-being in an academic environment. Med Educ 2004;38:465-78.  Back to cited text no. 31
Henzi D, Davis E, Jasinevicius R, Hendricson W, Cintron L, Isaacs M. Appraisal of the dental school learning environment: The student's view. J Dent Educ 2005;69:1137-47.  Back to cited text no. 32
Cardall WR, Rowan RC, Bay C. Dental education from the student's perspective: Curriculum and climate. J Dent Educ 2008;72:600-9.  Back to cited text no. 33
Hammond SM, O'Rourke M, Kelly M, Bennett D, O'Flynn S. Psychometric appraisal of the DREEM. BMC Med Educ 2012;12:2. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277479/pdf/1472-6920-12-2.pdf. [Last accessed on 2015 Nov 24].  Back to cited text no. 34
Henzi D, Davis E, Jasinevicius R, Hendricson W. In the students' own words: What are the strengths and weaknesses of the dental school curriculum? J Dent Educ 2007;71:632-45.  Back to cited text no. 35
Dahan H, Bedos C. A typology of dental students according to their experience of stress: A qualitative study. J Dent Educ 2010;74:95-103.  Back to cited text no. 36


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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