Eur Arch Paediatr Dent DOI 10.1007/s40368-014-0168-2
ORIGINAL SCIENTIFIC ARTICLE
Dentists’ self-perceived stress and difficulties when performing restorative treatment in children A. Rønneberg • K. Strøm • A. B. Skaare T. Willumsen • I. Espelid
•
Received: 22 September 2014 / Accepted: 5 December 2014 Ó European Academy of Paediatric Dentistry 2015
Abstract Aim This was to explore factors associated with dentists’ difficulties doing restorative treatment in children, in particular (1) stress, (2) clinical experience, (3) use of conscious sedation, and (4) use of local analgesia. Methods A precoded questionnaire (QuestBack) was sent electronically to all dentists working in the Public Dental Service (PDS) in eight counties in Norway. Chi-square statistics, McNemar’s test and bivariate logistic regression analyses were used. Results A total of 611 dentists received the questionnaire and 391 (65 %) returned the completed form. Self-reported stress was most frequent among dentists when treating patients aged 3–5 years and was statistically significantly associated with the dentists’ self-reported difficulties doing restorative treatment. Among dentists with B10 years experience about 60 % reported stress treating the youngest patients compared with 44 % among the more experienced dentists. Self-perceived stress and working experience was not associated with use of local analgesia and sedation.
A. Rønneberg (&) K. Strøm A. B. Skaare T. Willumsen I. Espelid Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, P.O. Box 1109, Blindern, 0455 Oslo, Norway e-mail: [email protected] K. Strøm e-mail: [email protected] A. B. Skaare e-mail: [email protected] T. Willumsen e-mail: [email protected] I. Espelid e-mail: [email protected]
Conclusions The frequency of self-perceived stress among dentists when undertaking restorative treatment decreased with increasing patient age from 3 to 18 years. When treating preschool children, a small group of dentists frequently or always experienced this as stressful work. The use of local analgesia or conscious sedation was not related to dentists’ stress. Dentists reported less frequently use of local analgesia and conscious sedation in children younger than 10 years. Undergraduate and continuous education and support in the use of local analgesia and conscious sedation is essential to provide optimal dental care for this patient group. Keywords Children Dental anxiety Dentist–patient relations Self-assessment Behavioural management
Introduction Stress may be defined as a feeling of strain and pressure. Small amounts of stress may be desirable, beneficial, and even healthy, but in this context, stress herein is defined as being negative or distress (Carver and Connor-Smith 2010). Distress is when a demand exceeds a person’s capabilities, for instance a dentist may feel distressed if, for some reason, providing the patient with optimal care is may be exceeding their capabilities. Distress is negative and may lead to physiological problems that could be harmful (Szabo et al. 2012). Health care professionals often have to perform under stressful conditions (LeBlanc 2009), and dentistry is challenging because it is a technological profession demanding a continually high skill level. Behaviour management problems (BMP) in children, the expectations and behaviour of accompanying parents, and the
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need to be cost effective, may be stressful and fatiguing for dentists in daily dental practice (O’Shea et al. 1984; Gale 1998; Hakanen et al. 2005; Klingberg and Broberg 2007; Gustafsson et al. 2010). Validation of self-reported mental stress using salivary cortisol as a biomarker was reviewed by Hjortskov et al. (2004). Four out of 14 studies reported a positive association. The review concluded that association between the cortisol levels and factors involving uncertainty novelty, lack of control, distress, anxiety and helplessness cannot be ruled out. Publications have focused upon the stress that dentists may experience when working with children. Many dentists perceive children’s behaviour that interferes with clinical procedures as stressful (Lowe 2013) and almost all dentists found it difficult to treat anxious children (Diercke et al. 2012). In striving for high technical quality in their work dentists may cause pain or anxiety in patients. This dilemma is reported to be important stressors for dentists (O’Shea et al. 1984; Gale 1998). A Swedish study (Hakeberg et al. 1992) showed that about 70 % of dentists ranked level of self-perceived stress as ‘‘very much’’ or ‘‘much’’ in the following situations: when patients do not appreciate the work, physically interrupt the work, do not cooperate in the chair or have unnecessary head movements. Treating fearful patients has been reported to be stressful, even in adult patients (Brahm et al. 2013). A British study demonstrated that 91 % of General Dental Practitioners (GDPs) felt stressed when treating anxious adult dental patients (Hill et al. 2008) and in Sweden, Brahm et al. (2012) reported that nearly 47 % of dentists suffered stress reactions. Patients and caregivers with poor cooperation, e.g. due to lack of motivation to care for their own or their child’s health, dentists easily feel powerless (Bedos et al. 2013). In addition, parents expect adequate oral care for their child and may not understand the complex operational challenges involved in treating anxious children, which may further increase a dentist’s stress. The length of time that a dentist has been in practice and their experience of completing restorative treatment may also influence their stress. In general, as dentists’ clinical experiences increases, they report a lower overall perception of stress (Rada and Johnson-Leong 2004). A study of Finnish health care workers (Vuori et al. 2014) showed a relationship between job strain and cognitive performance which might partially explain the negative effect of stress on work performance. It might be hypothesised that one barrier to optimal restorative treatment of children may relate to stress and emotions. Among medical students, perceived stress/overload and negative emotions affected performance in simulated resuscitation after cardiac arrest (Hunziker et al. 2011).
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When addressing improvement in quality of dental treatment for children, initiatives which makes treatment less difficult for dentists are important. Factors associated with dentists’ skills, such as the use of local analgesia (LA) and conscious sedation must be of special interest as these skills may be improved by competence building. The objective of this study was to explore factors which might be associated with dentists’ difficulties doing restorative treatment in children, in particular (1) selfperceived stress, (2) clinical experience, (3) use of conscious sedation and (4) use of LA.
Methods A precoded questionnaire was sent electronically in February 2013 to all dentists working in the Public Dental Service (PDS) in eight counties in Norway. All children in Norway are offered free comprehensive dental care from birth to 18 years of age in the PDS, and 95 % of the 5-yearolds are enrolled in the service. The counties were considered representative for the Norwegian population with respect to demographics. The respective Chief Dental Officers provided a total of 611 e-mail addresses for all employed dentists. An internet-based software program, QuestBack Norway (Oslo), ensured anonymity. The study was approved by the Norwegian Social Science Data Services. Two reminders were sent to non-responders 2 weeks apart. The age and sex distribution of respondents were checked against Statistics Norway’s dental registry on dentists employed in the PDS. The questionnaire was designed through a process within an interdisciplinary group. A pilot study was performed before the main survey and comments to the questionnaire were taken into account. The questionnaire included 32 questions of which eight were selected for analysis in the present study. A power analysis was performed to calculate the number of participants to be included. A test power of 80 % was selected to detect a difference in the replies between male and female dentists, if the difference was at least 10 % points. This required at least 402 participants in the study. A dropout of 30–40 % was chosen so the questionnaire was sent to 611 dentists. Inclusion criteria in the PDS, and treating children between 2 and 18 years of age at least once a week. Information was requested on the respondents’ sex, the data was country of education, years of practice as a dentist and time allocated for treatment of the age group 2–18 years. Each dentist’s report on years in practice was categorised into five groups: 0–5, 6–10, 11–15, 16–20 years and more than 20 years. In statistical analysis, dichotomised for the groups into practising ‘‘0–10 years’’ and ‘‘more than 10 years’’. Allocated treatment time with
Eur Arch Paediatr Dent
The regression analyses were performed with ‘‘difficulties doing restorative treatment in the age groups 3–5 and 6–9 years’’ as dependent variable, and dentists’ stress before treating anxious patients and years in practice as independent variables.
children and adolescents aged 2–18 years was precoded into 0–40, 41–60, 61–80 and 81–100 %. The four reply categories were dichotomised into 0–60 and 61–100 %. Questions on self-perception of carrying out restorative treatment in children and adolescents (2–18 years), and factors that might have an influence on dentists’ selfassessment were recorded. Questions were ‘‘How often do you find it difficult to do restorative treatment in children and adolescents?’’ and ‘‘How often do you use LA when completing restorative treatment in children and adolescents?’’ The response alternatives were never, rarely, sometimes, often and always, dichotomised into ‘‘never, rarely, sometimes’’ and ‘‘often, always’’. Regarding conscious sedation the following question were asked: ‘‘How often do you use conscious sedation to carry out treatment of patients between 2 and 18 years?’’ The response alternatives were never, rarely, 2–3 times every half year, 1–3 times every month or more and at least once a week’’, dichotomised into ‘‘never, rarely, 2–3 times every half year’’ and ‘‘1–3 times every month or more’’. The following question on dentists’ self-perception of treating patients with dental fear was included: ‘‘Do you feel stress before treating a patient that you know has dental fear?’’ This question has previously been used (Brahm et al. 2012) in a Swedish survey among adults. The question was translated from Swedish to Norwegian. The translation process followed standard procedures: the original Swedish survey was translated into Norwegian by two dentists fluent in both languages. These translations were then translated back to Swedish by two other dentists, also fluent in both languages. The translations were then compared with the original questionnaire and the best translation was used in the final Norwegian questionnaire. The five precoded responses were dichotomised into ‘‘never, rarely and sometimes’’ and ‘‘often, always’’. To analyse the data, SPSS version 21.0 (Statistical Package for the Social Sciences; SPSS Inc., Chicago, Ill., USA) was used. In the statistical analysis, we used crosstabulation with Chi-square and bivariate logistic regression analyses with p \ 0.05 selected as level of statistical significance. When comparing frequencies in two age groups of children, the McNemar’s test was used for significance testing. Table 1 Norwegian dentists’ responses to the question ‘‘How often do you find it difficult to complete restorative treatment’’ in different age groups
Age of patient
3–5 years
Dentist’s answer
n
Rarely/never
Results Of the 611 dentists invited, 12 declined to participate due to vacations, retirement or were no longer treating children and one was excluded because of an incomplete questionnaire. Of the remaining 598 dentists, 391 (65.4 %) responded; 270 (69.6 %) were female. Three dentists did not report their sex. There were no statistically significant differences between the study sample and all PDS dentists in Norway with respect to age (p = 0.31) and sex distribution (p = 0.43). The majority of the respondents (n = 288, 74.0 %) had been educated in Norway, while a quarter had studied abroad (n = 101, 26.0 %). Some of the included respondents did not answer all questions. The dentists’ own estimate of their ability to provide restorative treatment differed markedly between patients in different age groups (Table 1). The younger the child, the more frequently a dentist found it difficult to do restorative treatment. In the dentists’ estimation of difficulty, the lowest age group (3–5 years) was more difficult to treat than the other age groups (p \ 0.001). The proportion of dentists who found it frequently or always difficult to undertake restorative treatment decreased with increasing patient age; for example, comparing the age group 3–5 years with 6–9 years, the proportions of dentists reporting difficulty were 51.4 vs. 13.9 %, p \ 0.001. This proportion also differed between the age groups 6–9 and 10–14 years (13.9 vs. 1.3 %, p \ 0.001). The two oldest age groups did not differ significantly (p = 0.250). There was no statistically significant difference between male and female dentists with respect to how difficult they found it to undertake restorative treatment in the different age groups (Table 2).When comparing dentists educated in Norway and dentists educated abroad, there was no 6–9 years %
n
%
10–14 years
15–18 years
n
n
%
%
39
10.0
90
23.2
247
63.7
319
82.0
Sometimes
150
38.6
244
62.9
136
35.1
68
17.5
Frequently/always
200
51.4
54
13.9
5
1.3
2
0.5
Total
389
100.0
388
100.0
388
100.0
389
100.0
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Eur Arch Paediatr Dent Table 2 The proportion of dentists finding it frequently or always difficult to carryout restorative treatment
Age of patient
3–5 years
6–9 years
10–14 years
15–18 years
Dentists’ characteristics
n
n
n
n
%
%
%
%
Sex Women (n = 270) Men (n = 118)
141
52.2
38
14.2
3
1.1
1
0.4
58
50.0
16
13.7
2
1.7
1
0.9
140
48.8
36
12.6
2
0.7
2
0.7
58
58.0
18
17.8
3
3
0
0.0
110
59.8*
36
19.6*
2
1.1
0
0.0
90
43.9*
18
8.8*
3
1.5
2
0.5
51.4 50.9
31 22
14 13.5
3 2
1.4 1.2
2 0
0.9 0.0
174
48.5*
45
12.6*
4
1.1
2
0.6
25
86.2*
9
31.0*
1
3.4
0
0.0
Country of education Norway (n = 288) Other countries (n = 101) Years of practice 0–10 years More than 10 years
Allocated treatment time children aged 2–18 years 0–60 % 61–100 %
114 83
Dentists feeling stress when treating fearful patients Never, rarely, sometimes Often, always Dentists are categorised according to demographics, experience with treatment of children, self-perceived stress, years of practice, their use of local analgesia and sedation * Indicates statistically significant difference
Dentists’ use of local analgesia Never, rarely Sometimes Often, always
118
59.0
17
31.5
0
0.0
0
0.0
82
41.0
37
68.5
5
100.0
2
100.0
131
65.5
34
63.0
1
20.0
0
0.0
69
34.5
20
37.0
4
80.0
2
100.0
Dentists’ use of sedation Never, rarely, 2–3 times every half year 1–3 times every month or more
Table 3 A binary logistic regression model concerning the difficulty performing restorative treatment in children and adolescents as dependent variable and Norwegian dentists’ perception of stress and years in practice as independent variables Covariates
Difficult to do restorative treatment
Dentists felt stress before treating fearful patients
Rarely/never/sometimes
Years in practice
B10 years
Age groups 3–5 years
6–9 years
OR
95 % CI
OR
95 % CI
2.6
1.7–3.9
2.0
1.1–3.6
0.6
0.4–0.8
0.4
0.2–0.8
Frequently/always [10 years
statistically significant difference for a Norwegian child population regarding self-perception of ability to restore teeth in children and adolescents. The number of years in clinical practice was related to the reported difficulties doing restorative treatment in different age groups (Table 2). The five subgroups: 0–5, 6–10, 11–15, 16–20 years and more than 20 years were distributed as 31.7, 15.3, 10.2, 8.2 and 34.5 %, respectively. Among the least experienced dentists (B10 years of experience), 59.8 % reported frequently or always having difficulty completing restorations in children aged 3–5 years, as opposed to 43.9 % among the most experienced dentists ([10 years) (p = 0.002). The same pattern was found for
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the patient group 6–9 years of age, where 19.6 % of the least experienced group (B10 years of experience) reported frequently or always having difficulty doing restorative treatment, versus 8.8 % among the most experienced (p = 0.002). Among all dentists, 42.6 % spent more than 60 % of their clinical working hours with patients aged 2–18 years. Treatment time allocated to the age groups 2–18 years was not associated with difficulty doing restorative treatment (Table 2). Comparing dentists who were not stressed before treating patients with dental fear and dentists who were stressed, the latter experienced more often difficulties doing restorative treatment in children aged 3–5 years
Eur Arch Paediatr Dent Table 4 Dentists’ use of local analgesia when doing restorative treatment among children and adolescents
Age of patient
Dentist’ use of local analgesia 3–5 years
6–9 years
10–14 years
15–18 years
n
n
n
n
%
%
%
%
Dentists answer Never–rarely–sometimes
229
58.9
115
29.5
26
6.7
19
4.9
Frequently/always
160
41.1
275
70.5
364
93.3
371
95.1
Total
389
100.0
390
100.0
390
100.0
390
100.0
(48.5 vs. 86.2 %, p \ 0.001) and 6–9 years (12.6 vs. 31.0 %, p = 0.006), respectively. In the two oldest patient groups, no such difference was found. In treatment of the age groups 3–5 years, there was a statistically significant association between dentists feeling stress before treatment of patients with dental fear and difficulties associated with restorative treatment. There was a corresponding association with years in practice and selfreported stress; the group with more than 10 years of practice experienced less stress (Table 3). There was no statistically significant correlation between how often dentists reported using LA and how difficult they found doing restorative treatment among children and adolescents (Table 2). Dentists reported more frequently using LA among the oldest age groups (Table 4). Dentists’ use of sedation had no statistically significant association with how difficult they found doing restorative treatment on children and adolescents.
Discussion Dentists’ self-reported stress and years in practice were statistically significantly associated with difficulties doing restorative treatment. The younger the child, the more frequently a dentist found it difficult to complete restorative treatment, involving drilling procedures. Most often glass ionomer cement was used in the primary dentition, and resin composite in the permanent dentition. The response rate (65 %) was comparable with other reports (Chadwick et al. 2006; Hill et al. 2008; Brahm et al. 2013). Approximately half of the dentists employed in the PDS in Norway were invited to participate and the respondents constituted about one-third of all public dental officers in Norway. As there were no statistically significant differences between the study sample and all PDS dentists in Norway with respect to age and sex distribution, the sample was considered representative. It is nevertheless possible that relatively more foreign dentists were uncomfortable with the questionnaire in Norwegian and did not complete the survey.
Nearly 70 % of the respondents were women. This study demonstrated no sex inequalities regarding restorative treatment among children and adolescents. Several studies have shown that increasingly more women are entering health professions and the sex of the operator may have an effect on how patients are treated (Atchison et al. 2002; Grytten et al. 2002; Zitzmann et al. 2011). It has been reported that female physicians pay greater attention to social, preventive and human aspects of patient care than do male doctors (Maheux et al. 1989), but this tendency was not reflected in the present findings. The treatment time allocated to children and adolescents was not associated with how difficult the dentists found restorative treatment. Neither was country of education. However, years of clinical practice were associated with difficulties doing restorative treatment. Dentists who had worked 10 years or less reported more difficulties with the age groups 3–5 and 6–9 years. This may indicate that a greater degree of experience is needed to achieve confidence in different clinical situations. It has been shown that 64 % of Dutch dentists acknowledge the importance of treating children below 6 years, but they consider it stressful and time consuming (van Dam and Bruers 2003). Dentists’ own perception of stress in the treatment of patients with dental fear was also investigated. To our knowledge, no specific instrument has been developed to measure perceived stress among dentists performing restorative treatment. However, Brahm et al. (2012) reported on dentists’ stress when treating fearful adult patients. The same question was used in the present questionnaire. In the present study the term ‘‘dental fear’’ was used according to the above mentioned study. There is no clear distinctions made between the terms ‘‘dental fear’’ and ‘‘dental anxiety’’ in the literature. Problems associated with the definition of stress have been addressed by Marmot and Madge (1987). The concern of those authors was that there is a disagreement about the meaning of the term ‘‘stress’’ and its subsequent measurement, and also problems concerning causality in the stress-distress relationship. Self-perceived stress in this paper is defined with regard to how a dentist perceived fearful patients and how those patients affected them with stressfulness.
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The dentists who reported stress when treating patients with dental fear experienced more difficulty completing restorative treatment in the younger age groups. The same applied for dentists with less clinical experience, which supports the idea that clinical training and experience are of significance. Approximately 87 % of the dentists reported stress when undertaking restorative treatment in the age group 3–5 years, but this proportion declined significantly in the older age groups. This is in accordance with a German study (Diercke et al. 2012) where 90 % of dentists regarded treatment of anxious children as difficult. It is important to identify job-related stress as it is known to be a contributing factor in poor performance, low satisfaction and personal health problems (LaPorta 2010; Boran et al. 2012). There is reason to believe that demanding patient interactions may create stress in dentistry (Gorter et al. 1999). In Finland, pressure on dentists in the public sector has increased, and a good working environment for dentists also depends on the quality of the services they offer to their patients (Hakanen et al. 2005). Controlling patient anxiety adequately is an integral part of the practice of dentistry (Scottish Dental Clinical Effectiveness Programme 2012). LA is essential for painless dental treatment and dentists’ use of LA and sedation are important to prevent fear and anxiety in children. Developing dental fear can be mediated by experiences of pain, discomfort or unkind reception. As a consequence, a child may respond with BMP (Klingberg et al. 1995; Versloot et al. 2008). Milgrom et al. (1994) report that children disliked going to a dentist because it hurts. The present study demonstrated that almost 60 % of respondents reported that they never, rarely or sometimes used LA in children aged 3–5 years, whereas in the group 6–9 years, 30 % did not use LA when doing restorative treatment. This reveals that dentists use LA to a lesser extent among the youngest children compared with the oldest. This finding was not statistically significant, but must still be of reasonable concern. One strategy to overcome difficulties with dental treatment could be more use of premedication. Conscious sedation is often preferable as premedication in dental practice and is an alternative to general analgesia for patients with dental behaviour management problems and dental anxiety (Papineni et al. 2012). However, our study showed that dentists who reported difficulty doing restorative treatment did not use significantly more conscious sedation. Sedation may be required for some child patients to allow a dentist to deliver adequate and highquality dentistry. Conscious sedation of fearful children could also be important for the dentists’ stress and negative emotions when doing dental treatment. The results from this survey demonstrated that barely 34–37 % of the
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dentists who found it difficult to do restorative treatment in children younger than 10 years used conscious sedation. As children are the main target group for the use of conscious sedation in dental practice, these findings indicate that dentists’ use of sedation should be emphasised in dental undergraduate and continuing training programmes. Dental care for young people with major treatment needs requires the very skilled and committed conscientious clinicians. This study indicates that dentists are under stress when undertaking restorative treatment; those who had worked less than 10 years reported more difficulty and used LA and conscious sedation less frequently in children under 10 years. These findings are important when considering quality in dental practice and the delivery of good dental care. Holt and Ladwa (2008) focused on the need for mentoring in dental practice. The support of a mentor at times of stress or decision-making in different clinical situations has been shown to be beneficial (Holt and Ladwa 2009). Mentoring or coaching of dentists should receive greater attention when high-quality dentistry for children is the goal. Zhou et al. (2011) indicated that better knowledge of dental staff behaviours may prove to be fruitful when looking at the effect on child cooperation. Thus, to reduce dentists’ stress, factors that may lead to this stress when meeting with fearful children should receive increased attention. Further studies using validated tools for measuring stress among dentists treating children would be of great interest.
Conclusions In general, the frequency of self-perceived stress among dentists when undertaking restorative treatment of children and adolescents decreased with increasing age from 3 to 18 years. When treating preschool children aged 3–5 years, a small group of dentists frequently/always experienced this as being stressful work. Self-perceived stress, however, was not associated with the use of local analgesia or sedation. Less than 10 years of working experience as a dentist was associated with more difficulties performing restorative treatment. Dentists reported less frequent use of LA and conscious sedation in children younger than 10 years. Undergraduate and continuous education and support in the use of LA and conscious sedation is essential to provide optimal dental care for this patient group. Acknowledgments The authors would like to thank dentists in the Public Dental Service in the counties of Finnmark, Nordland, SørTrøndelag, Møre og Romsdal, Hordaland, Vest-Agder, Hedmark and Oslo for their contributions to the study.
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ORIGINAL SCIENTIFIC ARTICLE
Dentists’ self-perceived stress and difficulties when performing restorative treatment in children A. Rønneberg • K. Strøm • A. B. Skaare T. Willumsen • I. Espelid
•
Received: 22 September 2014 / Accepted: 5 December 2014 Ó European Academy of Paediatric Dentistry 2015
Abstract Aim This was to explore factors associated with dentists’ difficulties doing restorative treatment in children, in particular (1) stress, (2) clinical experience, (3) use of conscious sedation, and (4) use of local analgesia. Methods A precoded questionnaire (QuestBack) was sent electronically to all dentists working in the Public Dental Service (PDS) in eight counties in Norway. Chi-square statistics, McNemar’s test and bivariate logistic regression analyses were used. Results A total of 611 dentists received the questionnaire and 391 (65 %) returned the completed form. Self-reported stress was most frequent among dentists when treating patients aged 3–5 years and was statistically significantly associated with the dentists’ self-reported difficulties doing restorative treatment. Among dentists with B10 years experience about 60 % reported stress treating the youngest patients compared with 44 % among the more experienced dentists. Self-perceived stress and working experience was not associated with use of local analgesia and sedation.
A. Rønneberg (&) K. Strøm A. B. Skaare T. Willumsen I. Espelid Department of Paediatric Dentistry and Behavioural Science, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, P.O. Box 1109, Blindern, 0455 Oslo, Norway e-mail: [email protected] K. Strøm e-mail: [email protected] A. B. Skaare e-mail: [email protected] T. Willumsen e-mail: [email protected] I. Espelid e-mail: [email protected]
Conclusions The frequency of self-perceived stress among dentists when undertaking restorative treatment decreased with increasing patient age from 3 to 18 years. When treating preschool children, a small group of dentists frequently or always experienced this as stressful work. The use of local analgesia or conscious sedation was not related to dentists’ stress. Dentists reported less frequently use of local analgesia and conscious sedation in children younger than 10 years. Undergraduate and continuous education and support in the use of local analgesia and conscious sedation is essential to provide optimal dental care for this patient group. Keywords Children Dental anxiety Dentist–patient relations Self-assessment Behavioural management
Introduction Stress may be defined as a feeling of strain and pressure. Small amounts of stress may be desirable, beneficial, and even healthy, but in this context, stress herein is defined as being negative or distress (Carver and Connor-Smith 2010). Distress is when a demand exceeds a person’s capabilities, for instance a dentist may feel distressed if, for some reason, providing the patient with optimal care is may be exceeding their capabilities. Distress is negative and may lead to physiological problems that could be harmful (Szabo et al. 2012). Health care professionals often have to perform under stressful conditions (LeBlanc 2009), and dentistry is challenging because it is a technological profession demanding a continually high skill level. Behaviour management problems (BMP) in children, the expectations and behaviour of accompanying parents, and the
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need to be cost effective, may be stressful and fatiguing for dentists in daily dental practice (O’Shea et al. 1984; Gale 1998; Hakanen et al. 2005; Klingberg and Broberg 2007; Gustafsson et al. 2010). Validation of self-reported mental stress using salivary cortisol as a biomarker was reviewed by Hjortskov et al. (2004). Four out of 14 studies reported a positive association. The review concluded that association between the cortisol levels and factors involving uncertainty novelty, lack of control, distress, anxiety and helplessness cannot be ruled out. Publications have focused upon the stress that dentists may experience when working with children. Many dentists perceive children’s behaviour that interferes with clinical procedures as stressful (Lowe 2013) and almost all dentists found it difficult to treat anxious children (Diercke et al. 2012). In striving for high technical quality in their work dentists may cause pain or anxiety in patients. This dilemma is reported to be important stressors for dentists (O’Shea et al. 1984; Gale 1998). A Swedish study (Hakeberg et al. 1992) showed that about 70 % of dentists ranked level of self-perceived stress as ‘‘very much’’ or ‘‘much’’ in the following situations: when patients do not appreciate the work, physically interrupt the work, do not cooperate in the chair or have unnecessary head movements. Treating fearful patients has been reported to be stressful, even in adult patients (Brahm et al. 2013). A British study demonstrated that 91 % of General Dental Practitioners (GDPs) felt stressed when treating anxious adult dental patients (Hill et al. 2008) and in Sweden, Brahm et al. (2012) reported that nearly 47 % of dentists suffered stress reactions. Patients and caregivers with poor cooperation, e.g. due to lack of motivation to care for their own or their child’s health, dentists easily feel powerless (Bedos et al. 2013). In addition, parents expect adequate oral care for their child and may not understand the complex operational challenges involved in treating anxious children, which may further increase a dentist’s stress. The length of time that a dentist has been in practice and their experience of completing restorative treatment may also influence their stress. In general, as dentists’ clinical experiences increases, they report a lower overall perception of stress (Rada and Johnson-Leong 2004). A study of Finnish health care workers (Vuori et al. 2014) showed a relationship between job strain and cognitive performance which might partially explain the negative effect of stress on work performance. It might be hypothesised that one barrier to optimal restorative treatment of children may relate to stress and emotions. Among medical students, perceived stress/overload and negative emotions affected performance in simulated resuscitation after cardiac arrest (Hunziker et al. 2011).
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When addressing improvement in quality of dental treatment for children, initiatives which makes treatment less difficult for dentists are important. Factors associated with dentists’ skills, such as the use of local analgesia (LA) and conscious sedation must be of special interest as these skills may be improved by competence building. The objective of this study was to explore factors which might be associated with dentists’ difficulties doing restorative treatment in children, in particular (1) selfperceived stress, (2) clinical experience, (3) use of conscious sedation and (4) use of LA.
Methods A precoded questionnaire was sent electronically in February 2013 to all dentists working in the Public Dental Service (PDS) in eight counties in Norway. All children in Norway are offered free comprehensive dental care from birth to 18 years of age in the PDS, and 95 % of the 5-yearolds are enrolled in the service. The counties were considered representative for the Norwegian population with respect to demographics. The respective Chief Dental Officers provided a total of 611 e-mail addresses for all employed dentists. An internet-based software program, QuestBack Norway (Oslo), ensured anonymity. The study was approved by the Norwegian Social Science Data Services. Two reminders were sent to non-responders 2 weeks apart. The age and sex distribution of respondents were checked against Statistics Norway’s dental registry on dentists employed in the PDS. The questionnaire was designed through a process within an interdisciplinary group. A pilot study was performed before the main survey and comments to the questionnaire were taken into account. The questionnaire included 32 questions of which eight were selected for analysis in the present study. A power analysis was performed to calculate the number of participants to be included. A test power of 80 % was selected to detect a difference in the replies between male and female dentists, if the difference was at least 10 % points. This required at least 402 participants in the study. A dropout of 30–40 % was chosen so the questionnaire was sent to 611 dentists. Inclusion criteria in the PDS, and treating children between 2 and 18 years of age at least once a week. Information was requested on the respondents’ sex, the data was country of education, years of practice as a dentist and time allocated for treatment of the age group 2–18 years. Each dentist’s report on years in practice was categorised into five groups: 0–5, 6–10, 11–15, 16–20 years and more than 20 years. In statistical analysis, dichotomised for the groups into practising ‘‘0–10 years’’ and ‘‘more than 10 years’’. Allocated treatment time with
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The regression analyses were performed with ‘‘difficulties doing restorative treatment in the age groups 3–5 and 6–9 years’’ as dependent variable, and dentists’ stress before treating anxious patients and years in practice as independent variables.
children and adolescents aged 2–18 years was precoded into 0–40, 41–60, 61–80 and 81–100 %. The four reply categories were dichotomised into 0–60 and 61–100 %. Questions on self-perception of carrying out restorative treatment in children and adolescents (2–18 years), and factors that might have an influence on dentists’ selfassessment were recorded. Questions were ‘‘How often do you find it difficult to do restorative treatment in children and adolescents?’’ and ‘‘How often do you use LA when completing restorative treatment in children and adolescents?’’ The response alternatives were never, rarely, sometimes, often and always, dichotomised into ‘‘never, rarely, sometimes’’ and ‘‘often, always’’. Regarding conscious sedation the following question were asked: ‘‘How often do you use conscious sedation to carry out treatment of patients between 2 and 18 years?’’ The response alternatives were never, rarely, 2–3 times every half year, 1–3 times every month or more and at least once a week’’, dichotomised into ‘‘never, rarely, 2–3 times every half year’’ and ‘‘1–3 times every month or more’’. The following question on dentists’ self-perception of treating patients with dental fear was included: ‘‘Do you feel stress before treating a patient that you know has dental fear?’’ This question has previously been used (Brahm et al. 2012) in a Swedish survey among adults. The question was translated from Swedish to Norwegian. The translation process followed standard procedures: the original Swedish survey was translated into Norwegian by two dentists fluent in both languages. These translations were then translated back to Swedish by two other dentists, also fluent in both languages. The translations were then compared with the original questionnaire and the best translation was used in the final Norwegian questionnaire. The five precoded responses were dichotomised into ‘‘never, rarely and sometimes’’ and ‘‘often, always’’. To analyse the data, SPSS version 21.0 (Statistical Package for the Social Sciences; SPSS Inc., Chicago, Ill., USA) was used. In the statistical analysis, we used crosstabulation with Chi-square and bivariate logistic regression analyses with p \ 0.05 selected as level of statistical significance. When comparing frequencies in two age groups of children, the McNemar’s test was used for significance testing. Table 1 Norwegian dentists’ responses to the question ‘‘How often do you find it difficult to complete restorative treatment’’ in different age groups
Age of patient
3–5 years
Dentist’s answer
n
Rarely/never
Results Of the 611 dentists invited, 12 declined to participate due to vacations, retirement or were no longer treating children and one was excluded because of an incomplete questionnaire. Of the remaining 598 dentists, 391 (65.4 %) responded; 270 (69.6 %) were female. Three dentists did not report their sex. There were no statistically significant differences between the study sample and all PDS dentists in Norway with respect to age (p = 0.31) and sex distribution (p = 0.43). The majority of the respondents (n = 288, 74.0 %) had been educated in Norway, while a quarter had studied abroad (n = 101, 26.0 %). Some of the included respondents did not answer all questions. The dentists’ own estimate of their ability to provide restorative treatment differed markedly between patients in different age groups (Table 1). The younger the child, the more frequently a dentist found it difficult to do restorative treatment. In the dentists’ estimation of difficulty, the lowest age group (3–5 years) was more difficult to treat than the other age groups (p \ 0.001). The proportion of dentists who found it frequently or always difficult to undertake restorative treatment decreased with increasing patient age; for example, comparing the age group 3–5 years with 6–9 years, the proportions of dentists reporting difficulty were 51.4 vs. 13.9 %, p \ 0.001. This proportion also differed between the age groups 6–9 and 10–14 years (13.9 vs. 1.3 %, p \ 0.001). The two oldest age groups did not differ significantly (p = 0.250). There was no statistically significant difference between male and female dentists with respect to how difficult they found it to undertake restorative treatment in the different age groups (Table 2).When comparing dentists educated in Norway and dentists educated abroad, there was no 6–9 years %
n
%
10–14 years
15–18 years
n
n
%
%
39
10.0
90
23.2
247
63.7
319
82.0
Sometimes
150
38.6
244
62.9
136
35.1
68
17.5
Frequently/always
200
51.4
54
13.9
5
1.3
2
0.5
Total
389
100.0
388
100.0
388
100.0
389
100.0
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Eur Arch Paediatr Dent Table 2 The proportion of dentists finding it frequently or always difficult to carryout restorative treatment
Age of patient
3–5 years
6–9 years
10–14 years
15–18 years
Dentists’ characteristics
n
n
n
n
%
%
%
%
Sex Women (n = 270) Men (n = 118)
141
52.2
38
14.2
3
1.1
1
0.4
58
50.0
16
13.7
2
1.7
1
0.9
140
48.8
36
12.6
2
0.7
2
0.7
58
58.0
18
17.8
3
3
0
0.0
110
59.8*
36
19.6*
2
1.1
0
0.0
90
43.9*
18
8.8*
3
1.5
2
0.5
51.4 50.9
31 22
14 13.5
3 2
1.4 1.2
2 0
0.9 0.0
174
48.5*
45
12.6*
4
1.1
2
0.6
25
86.2*
9
31.0*
1
3.4
0
0.0
Country of education Norway (n = 288) Other countries (n = 101) Years of practice 0–10 years More than 10 years
Allocated treatment time children aged 2–18 years 0–60 % 61–100 %
114 83
Dentists feeling stress when treating fearful patients Never, rarely, sometimes Often, always Dentists are categorised according to demographics, experience with treatment of children, self-perceived stress, years of practice, their use of local analgesia and sedation * Indicates statistically significant difference
Dentists’ use of local analgesia Never, rarely Sometimes Often, always
118
59.0
17
31.5
0
0.0
0
0.0
82
41.0
37
68.5
5
100.0
2
100.0
131
65.5
34
63.0
1
20.0
0
0.0
69
34.5
20
37.0
4
80.0
2
100.0
Dentists’ use of sedation Never, rarely, 2–3 times every half year 1–3 times every month or more
Table 3 A binary logistic regression model concerning the difficulty performing restorative treatment in children and adolescents as dependent variable and Norwegian dentists’ perception of stress and years in practice as independent variables Covariates
Difficult to do restorative treatment
Dentists felt stress before treating fearful patients
Rarely/never/sometimes
Years in practice
B10 years
Age groups 3–5 years
6–9 years
OR
95 % CI
OR
95 % CI
2.6
1.7–3.9
2.0
1.1–3.6
0.6
0.4–0.8
0.4
0.2–0.8
Frequently/always [10 years
statistically significant difference for a Norwegian child population regarding self-perception of ability to restore teeth in children and adolescents. The number of years in clinical practice was related to the reported difficulties doing restorative treatment in different age groups (Table 2). The five subgroups: 0–5, 6–10, 11–15, 16–20 years and more than 20 years were distributed as 31.7, 15.3, 10.2, 8.2 and 34.5 %, respectively. Among the least experienced dentists (B10 years of experience), 59.8 % reported frequently or always having difficulty completing restorations in children aged 3–5 years, as opposed to 43.9 % among the most experienced dentists ([10 years) (p = 0.002). The same pattern was found for
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the patient group 6–9 years of age, where 19.6 % of the least experienced group (B10 years of experience) reported frequently or always having difficulty doing restorative treatment, versus 8.8 % among the most experienced (p = 0.002). Among all dentists, 42.6 % spent more than 60 % of their clinical working hours with patients aged 2–18 years. Treatment time allocated to the age groups 2–18 years was not associated with difficulty doing restorative treatment (Table 2). Comparing dentists who were not stressed before treating patients with dental fear and dentists who were stressed, the latter experienced more often difficulties doing restorative treatment in children aged 3–5 years
Eur Arch Paediatr Dent Table 4 Dentists’ use of local analgesia when doing restorative treatment among children and adolescents
Age of patient
Dentist’ use of local analgesia 3–5 years
6–9 years
10–14 years
15–18 years
n
n
n
n
%
%
%
%
Dentists answer Never–rarely–sometimes
229
58.9
115
29.5
26
6.7
19
4.9
Frequently/always
160
41.1
275
70.5
364
93.3
371
95.1
Total
389
100.0
390
100.0
390
100.0
390
100.0
(48.5 vs. 86.2 %, p \ 0.001) and 6–9 years (12.6 vs. 31.0 %, p = 0.006), respectively. In the two oldest patient groups, no such difference was found. In treatment of the age groups 3–5 years, there was a statistically significant association between dentists feeling stress before treatment of patients with dental fear and difficulties associated with restorative treatment. There was a corresponding association with years in practice and selfreported stress; the group with more than 10 years of practice experienced less stress (Table 3). There was no statistically significant correlation between how often dentists reported using LA and how difficult they found doing restorative treatment among children and adolescents (Table 2). Dentists reported more frequently using LA among the oldest age groups (Table 4). Dentists’ use of sedation had no statistically significant association with how difficult they found doing restorative treatment on children and adolescents.
Discussion Dentists’ self-reported stress and years in practice were statistically significantly associated with difficulties doing restorative treatment. The younger the child, the more frequently a dentist found it difficult to complete restorative treatment, involving drilling procedures. Most often glass ionomer cement was used in the primary dentition, and resin composite in the permanent dentition. The response rate (65 %) was comparable with other reports (Chadwick et al. 2006; Hill et al. 2008; Brahm et al. 2013). Approximately half of the dentists employed in the PDS in Norway were invited to participate and the respondents constituted about one-third of all public dental officers in Norway. As there were no statistically significant differences between the study sample and all PDS dentists in Norway with respect to age and sex distribution, the sample was considered representative. It is nevertheless possible that relatively more foreign dentists were uncomfortable with the questionnaire in Norwegian and did not complete the survey.
Nearly 70 % of the respondents were women. This study demonstrated no sex inequalities regarding restorative treatment among children and adolescents. Several studies have shown that increasingly more women are entering health professions and the sex of the operator may have an effect on how patients are treated (Atchison et al. 2002; Grytten et al. 2002; Zitzmann et al. 2011). It has been reported that female physicians pay greater attention to social, preventive and human aspects of patient care than do male doctors (Maheux et al. 1989), but this tendency was not reflected in the present findings. The treatment time allocated to children and adolescents was not associated with how difficult the dentists found restorative treatment. Neither was country of education. However, years of clinical practice were associated with difficulties doing restorative treatment. Dentists who had worked 10 years or less reported more difficulties with the age groups 3–5 and 6–9 years. This may indicate that a greater degree of experience is needed to achieve confidence in different clinical situations. It has been shown that 64 % of Dutch dentists acknowledge the importance of treating children below 6 years, but they consider it stressful and time consuming (van Dam and Bruers 2003). Dentists’ own perception of stress in the treatment of patients with dental fear was also investigated. To our knowledge, no specific instrument has been developed to measure perceived stress among dentists performing restorative treatment. However, Brahm et al. (2012) reported on dentists’ stress when treating fearful adult patients. The same question was used in the present questionnaire. In the present study the term ‘‘dental fear’’ was used according to the above mentioned study. There is no clear distinctions made between the terms ‘‘dental fear’’ and ‘‘dental anxiety’’ in the literature. Problems associated with the definition of stress have been addressed by Marmot and Madge (1987). The concern of those authors was that there is a disagreement about the meaning of the term ‘‘stress’’ and its subsequent measurement, and also problems concerning causality in the stress-distress relationship. Self-perceived stress in this paper is defined with regard to how a dentist perceived fearful patients and how those patients affected them with stressfulness.
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The dentists who reported stress when treating patients with dental fear experienced more difficulty completing restorative treatment in the younger age groups. The same applied for dentists with less clinical experience, which supports the idea that clinical training and experience are of significance. Approximately 87 % of the dentists reported stress when undertaking restorative treatment in the age group 3–5 years, but this proportion declined significantly in the older age groups. This is in accordance with a German study (Diercke et al. 2012) where 90 % of dentists regarded treatment of anxious children as difficult. It is important to identify job-related stress as it is known to be a contributing factor in poor performance, low satisfaction and personal health problems (LaPorta 2010; Boran et al. 2012). There is reason to believe that demanding patient interactions may create stress in dentistry (Gorter et al. 1999). In Finland, pressure on dentists in the public sector has increased, and a good working environment for dentists also depends on the quality of the services they offer to their patients (Hakanen et al. 2005). Controlling patient anxiety adequately is an integral part of the practice of dentistry (Scottish Dental Clinical Effectiveness Programme 2012). LA is essential for painless dental treatment and dentists’ use of LA and sedation are important to prevent fear and anxiety in children. Developing dental fear can be mediated by experiences of pain, discomfort or unkind reception. As a consequence, a child may respond with BMP (Klingberg et al. 1995; Versloot et al. 2008). Milgrom et al. (1994) report that children disliked going to a dentist because it hurts. The present study demonstrated that almost 60 % of respondents reported that they never, rarely or sometimes used LA in children aged 3–5 years, whereas in the group 6–9 years, 30 % did not use LA when doing restorative treatment. This reveals that dentists use LA to a lesser extent among the youngest children compared with the oldest. This finding was not statistically significant, but must still be of reasonable concern. One strategy to overcome difficulties with dental treatment could be more use of premedication. Conscious sedation is often preferable as premedication in dental practice and is an alternative to general analgesia for patients with dental behaviour management problems and dental anxiety (Papineni et al. 2012). However, our study showed that dentists who reported difficulty doing restorative treatment did not use significantly more conscious sedation. Sedation may be required for some child patients to allow a dentist to deliver adequate and highquality dentistry. Conscious sedation of fearful children could also be important for the dentists’ stress and negative emotions when doing dental treatment. The results from this survey demonstrated that barely 34–37 % of the
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dentists who found it difficult to do restorative treatment in children younger than 10 years used conscious sedation. As children are the main target group for the use of conscious sedation in dental practice, these findings indicate that dentists’ use of sedation should be emphasised in dental undergraduate and continuing training programmes. Dental care for young people with major treatment needs requires the very skilled and committed conscientious clinicians. This study indicates that dentists are under stress when undertaking restorative treatment; those who had worked less than 10 years reported more difficulty and used LA and conscious sedation less frequently in children under 10 years. These findings are important when considering quality in dental practice and the delivery of good dental care. Holt and Ladwa (2008) focused on the need for mentoring in dental practice. The support of a mentor at times of stress or decision-making in different clinical situations has been shown to be beneficial (Holt and Ladwa 2009). Mentoring or coaching of dentists should receive greater attention when high-quality dentistry for children is the goal. Zhou et al. (2011) indicated that better knowledge of dental staff behaviours may prove to be fruitful when looking at the effect on child cooperation. Thus, to reduce dentists’ stress, factors that may lead to this stress when meeting with fearful children should receive increased attention. Further studies using validated tools for measuring stress among dentists treating children would be of great interest.
Conclusions In general, the frequency of self-perceived stress among dentists when undertaking restorative treatment of children and adolescents decreased with increasing age from 3 to 18 years. When treating preschool children aged 3–5 years, a small group of dentists frequently/always experienced this as being stressful work. Self-perceived stress, however, was not associated with the use of local analgesia or sedation. Less than 10 years of working experience as a dentist was associated with more difficulties performing restorative treatment. Dentists reported less frequent use of LA and conscious sedation in children younger than 10 years. Undergraduate and continuous education and support in the use of LA and conscious sedation is essential to provide optimal dental care for this patient group. Acknowledgments The authors would like to thank dentists in the Public Dental Service in the counties of Finnmark, Nordland, SørTrøndelag, Møre og Romsdal, Hordaland, Vest-Agder, Hedmark and Oslo for their contributions to the study.
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