Eur J Dent Educ 2002; 6: 2229

Printed in Denmark. All rights reserved

Copyright C Munksgaard 2002

ISSN 1396-5883

Psychological stress in undergraduate dental students:

baseline results from seven European dental schools
Gerry Humphris1, Andy Blinkhorn2, Ruth Freeman3, Ronald Gorter4, Gillian Hoad-Reddick2,
Heikki Murtomaa5, Robin OSullivan6 and Christian Splieth7
1
Department of Clinical Psychology, University of Liverpool, UK; 2Oral Health and Development, University of Manchester Dental Hospital, Higher
Cambridge Street, Manchester, M15 6FH, UK; 3Dental Public Health Research Group, Queens University of Belfast, UK; 4Department of Social Dentistry
and Dental Health Education, Academic Centre for Dentistry Amsterdam (ACTA), Louwesweg 1, 1066 EA Amsterdam, The Netherlands; 5Helsinki
International Institute for Oral Health, University of Helsinki, Finland; 6Department of Anatomy, University College, Cork, Ireland; 7Ernst-MoritzArndt-Universitat, Greifswald, Rotgerberstrasse 8, D-17487, Germany

Objectives: To determine the degree of psychological distress,

the experience of emotional exhaustion, and the extent of stress
associated with course work in dental students and to compare
these measurements among seven European dental schools.
Design: Multi-centred survey.
Setting: Dental Schools at Amsterdam, Belfast, Cork, Greifswald, Helsinki, Liverpool and Manchester.
Participants: 333 undergraduate first-year dental students.
Measures: General Health Questionnaire (GHQ12), Maslach
Burnout Inventory (MBI), Dental Environment Stress Questionnaire (DES), demographic variables.
Procedure: Questionnaire administered to all students attending
first year course. Completed questionnaires sent to central office
for processing.
Results: Seventy-nine percent of the sampled students responded. Over a third of the students (36%) reported significant

psychological distress (morbidity) at the recommended cut-off

point (3 on GHQ). These scores were similar to those reported
for medical undergraduates. Twenty-two percent recorded comparatively high scores on emotional exhaustion. A wide variation
in these 2 measurements was found across schools (ps0.001).
Stress levels indicated by the DES were less variable (p0.5).
Some evidence showed that contact with patients and the level
of support afforded by living at home may be protective.
Conclusion: Higher than expected levels of emotional exhaustion were found in a large sample of first-year undergraduate
dental students in Europe.

ment. Dentists who experience burnout are unable to

continue working, find the interaction with patients
unbearable and withdraw from contact with staff and
colleagues (911).
While occupational stress and burnout is well-recognised in qualified dentists, little is known about the
influence of dental undergraduate training on the
evolution of occupational stress and burnout in students. Many studies (1216) have examined occupational stress in dental undergraduates and have
shown that the concerns of clinical students mirror
those of qualified practitioners. However, many of
these previous investigations were cross-sectional in
nature and could neither identify susceptible individuals, nor associate the development of occupational
stress and/or burnout with undergraduate training.
Some investigators examined the association of environmental factors over a period of time with stress
levels reported by students. An interesting study com-

profession has been considered the

most stressful of all the health professions (1).
Documented evidence for this claim is required (2),
although it is known that dentists may experience occupational stress from their interaction with patients
and staff, fears of physical violence or litigation from
their patients, concerns about the financial viability of
their practice resulting from defective materials and
equipment (36). Occupational stress can be defined
as a state of physical and mental tension resulting
from excessive demands or lack of resources (after Lovallo, 1997) (7). In chronic or extreme circumstances
occupational stress can precipitate a state of burnout
in the susceptible practitioner. Maslach and Jackson
(8) have described burnout as a unique response to
frequent and intense clinician-patient contacts consisting of three components: emotional exhaustion (mental fatigue), depersonalisation (psychological distancing from others) and reduced personal accomplish-

22

HE DENTAL

Key words: stress; burnout; dental students; mental health.

c Munksgaard, 2002
Accepted for publication 3 April 2001

The European Dental Student Stress Project

pared senior dental students at a school in Israel with

students who had attended the same school some 10
years previously, and found similar levels of stress in
the two groups. This finding was unexpected since
considerable changes in the curriculum had been introduced during the intervening decade (17). Recently
Freeman et al. (18), compared clinical dental students
in 1992 and 1995, and found little difference in levels
of stress. This was an unexpected finding, as the former sample of students were exposed to the troubles
in Northern Ireland at the time of the original questionnaire completion.
Few studies have attempted to compare stress
levels in different schools employing alternative
teaching methods within their cultural context. A
study limited to two schools by Yap et al. (19) reported a cross-cultural comparison between Singaporean and American dental students. The concerns
expressed by the students about their courses related
to different areas within the curriculum of each
school. Hence, some evidence can be presented demonstrating the limited effects of the external environment on dental student stress. Variations of students
stress appear to result from internal factors related to
the course, or to their immediate surroundings. To
confirm the tentative finding that stress levels was dependent on specific curriculum issues of the school
concerned, or on factors closely relevant to student
life, further assessment of dental student stress from
a number of schools in different countries was warranted.
The assessment of stress in dental students and its
possible relationship to different methods of teaching
is an important area of concern. In addition, it would
be useful to examine the effect of stress on the psychological health and well-being of dental students in order to assist understanding the process of burnout.
Various models have been presented to help explain
the effects of stress on the individual. A notable example is the stress appraisal-coping model of Lazarus
and Folkman (20). Appraisal of stressors, resulting in
either strain or coping is a key element of these frameworks, including the Lazarus and Folkman model.
Emotional exhaustion has been put forward as an example of strain, depersonalisation as a form of defensive coping and personal accomplishment as an element of self-evaluation (21). Although the causal relationships between these variables are poorly understood, there is a need to investigate burnout at various
stages of the dentists working life. We are not aware
of studies that have investigated burnout in dental
undergraduates during their first encounters with patients. Cherniss (22) has suggested that burnout can

develop within one year of patient contact. In support

of this approach, Guthrie et al. (23) have shown that
psychological distress (psychological morbidity) in
first-year medical undergraduates was predictive of
occupational stress in later years.
This paper presents the first results from a longitudinal study involving seven European dental
schools. The focus of our research is to establish the
initial effects of undergraduate training upon the development of occupational stress and burnout in those
studying to be dentists. A clearer understanding of
the factors associated with the development of stress
and burnout in the early years of training should help
dental educators to design more sympathetic and
valuable teaching programmes. The aim of the present study was to assess the prevalence of psychological distress in first-year dental undergraduates in
seven European dental schools. The objectives were
(i) to determine the degree of psychological distress,
the experience of emotional exhaustion and the extent
of stress associated with course work, (ii) to compare
these measurements of psychological distress among
the seven European dental schools, and (iii) to determine the impact of various course features and immediate environmental factors on these distress
levels.

Method
The dental schools invited to take part in the longitudinal study were chosen as they had the resources
and personnel recognised in the research area of occupational stress in dentistry. All first-year dental students at the universities in Amsterdam, Belfast, Cork,
Greifswald, Helsinki, Liverpool and Manchester were
invited to take part.

The questionnaire
The baseline questionnaire was divided into 2 sections. The first section recorded demographic details,
place of study, term-time accommodation (that is, the
students residence during the teaching period at the
dental school), alcohol and tobacco consumption, and
perceptions of physical health (using the Occupational Stress Indicator: Physical Health sub-scale of
12 items with a split-half reliability coefficient of 0.73)
(24). Assessments were made for each participant.
The second section comprised the following three
components:
(i) The 12-item General Health Questionnaire
[GHQ] (25), which has good reliability and validity when assessing psychological distress in

23

Humphris et al.

young populations (26). It is easy to administer

and score, with a clear cut-off point (3) which
can be used to determine the prevalence of
psychological ill-health (27).
(ii) The Maslach Burnout Inventory [MBI] (24). This
has a 22-item inventory which assesses three aspects of burnout emotional exhaustion, depersonalisation and personal achievement using a
6-point Likert scale ranging from never (scoring
0) to every day (scoring 6). The MBI was chosen
as it has been shown to have good validity and
reliability in the measurement of burnout in dental practitioners (11, 28).
(iii) The Dental Environment Stress questionnaire
[DES] (29), which assesses sources of stress associated with undergraduate course work and
training in dental students. It is a 38-item questionnaire based on a 4-point Likert scale, with
scores ranging from 1 (not stressful) to 4 (very
stressful). Example items include difficulty of
classwork, lack of confidence to be a successful
dental student and fear of failing course. A
short form of the DES was used devised by the
authors (available on request). Of the full scale,
16 items were utilised and summed to form a
composite Likert scale. Items that referred to
stressors involving some reference to patients
had to be omitted.

Procedure and statistical analysis

The participating dental schools arranged for the
questionnaire to be completed in the students second
term of study. The timing of questionnaire completion
was independent of their assessment period. The
completed questionnaires were returned to a central
office (University of Manchester) for coding and data
entry. Statistical analysis was by SPSS version 10 and
included frequency distributions, chi-square analysis,
t-tests and analysis of variance. Chi-square analysis
and ANOVA were used to compare perceptions of
stress and burnout between centres. Alpha level was
set to the conventional 0.05. The study was powered
(80%) to detect a difference in means of 2 units on
the primary outcome variable (GHQ) using a 2-sided
significance level t-test.

Results
Sample
The size of intake to each school varied considerably
(see Table 1). The ACTA, Amsterdam, dental school
accepted approximately 140 students, compared to
Helsinki, which accepted around 30 students. The
overall response rate was 79.1% (331/418) for the
study sample with school rates varying from 54% in
Liverpool to 98% in Greifswald.

TABLE 1. Details of courses

Total first
year
intake

Patient
contact

Dental
clinical
patient
contact

Principal subjects covered*

Assessment

Teaching**
method
(philosophy)

136

Yes

Yes

Multiple choice, written papers,

short answer papers, clinical skills

PBL, L, T, P

Belfast

41

Yes

No

Written papers OSCE clinical skills

SDL, C, L, T, P

Cork

42

No

No

40

No

No

Multiple choice, essay papers,

short answer papers, oral
examination
Written test (during year)
Oral examination

L, T, P

Greifswald

Helsinki

30

Yes

No

Human biology, social dentistry,

theory and practice of dental
clinical skills
Cell biology, systems, introduction
to clinical skills. IGS, dental
anatomy
Biochemistry, physiology, systemic
and topographical anatomy,
general histology
Physics, chemistry, zoology,
anatomy introduction to clinical
skills and prosthetics laboratory
work
Integrated basic sciences

PBL

Liverpool

50

Yes

No

Manchester

75

Yes

No

Written papers, multiple choice,

essay papers
Multiple choice, OSCE clinical
skills, critical appraisal paper
Multiple choice, short answer
papers, continuous assessment

Amsterdam

IGS, Communication skills,

preventive dentistry
Systems based cardio-respiratory
fitness nutrition and metabolism

* IGS individual, groups & society.

** PBLproblem based learning, SDLself directed learning, LLectures, TTutorials, PPractical, CCommunity.

24

L, P

PBL
PBL, L, P

The European Dental Student Stress Project

First-year course characteristics

the schools differed strongly in their age composition

(c272.45, df6, p0.001). For example, only 14% of the
Cork students were in the older category compared
with 83% of those in Helsinki.
The greatest proportion of students (40%) was
housed in University residence halls or their own accommodation (37%); less than a quarter (23%) resided
at home. The breakdown of student living accommodation differed by school (c2103.7, df12, p0.001):
nearly 80% of Manchester students lived in hall,
whereas in Helsinki and Greifswald many students
resided in their own accommodation (66% and 68%
respectively), and a large proportion of Amsterdam
students lived at home (38%).

The subjects that were taught in the first year reflected

a strong basic science theme, although some courses
also introduced students to applied topics, such as
clinical skills teaching and laboratory work. Less
popular were the clinical or oral examinations. The
Cork and Greifswald schools followed more traditional methods of teaching based upon lectures, tutorials and practicals. The other schools favoured
problem-based learning, supplemented in some by
traditional methods and self-directed learning. Supporters of problem-based learning consider it more
student-orientated, in that the students make assessments of their learning needs and pursue a set of
unique, self-defined learning objectives. On this basis,
some authorities argue that these methods lower
course anxiety (30).
The Cork and Greifswald schools did not have organised patient contact. Other schools provided their
students with the opportunity to meet patients, to
take brief histories and to deliver health education
messages, but did not organise clinical examinations
or interventions. Only in Amsterdam did clinical patient contact occur. Assessment systems included
written tests or multiple-choice questions in virtually
every course.

Measures of psychological distress, burnout and

environmental stress
To assess the variation of these three psychological
constructs across the sampled dental schools, the students were divided into high and low scorers on the
basis of recognised cut-offs.
General Health Questionnaire (GHQ12). The internal consistency (Cronbachs alpha) of the 12 item scale
of psychological distress, using the 0123 Likert
scoring convention, for the present sample was 0.87.
For the purposes of presenting case level, the 0-0-1-1
scoring system was adopted. Approximately a third
(36%) of the total sample of students were found to
report psychological distress (morbidity) at a level to
cause some concern (see Table 3). The case level
varied substantially between schools (c225.94, df6,
p0.001). Nearly two thirds (62%) of Greifswald students were found to score above the cut-off level,
whereas Helsinki students showed a low case level
proportion (10%).
Maslach Burnout Inventory (MBI). The emotional

Demographic profile of the sample

The gender split for the whole sample was virtually
50:50 (see Table 2). The male/female ratio by school
showed wide variation (c214.11, df6, p0.03), with
the proportion of women ranging from 39% to 78%.
Student age was recorded under two headings: 1819
years old, and 20 years old and above. Nearly equal
proportions were found: 48% in the younger age
group and 52% in the older. The student samples from

TABLE 2. Demographic details by Dental School

Dental schools

Male
N
Amsterdam
Belfast
Cork
Greifswald
Helsinki
Liverpool
Manchester
Total

Age

Gender*

Accommodation

Female

1819 years

20 years

With family

University halls

Own accommodation

55
17
16
27
13
6
33

56
44
46
61
45
22
57

44
22
19
17
16
21
25

44
56
54
39
55
78
43

38
31
30
10
5
7
37

38
80
86
23
17
26
64

61
8
5
34
24
20
21

62
20
14
77
83
74
36

38
9
13
3
4
2
9

38
23
37
7
14
7
16

25
23
5
11
6
16
45

25
59
14
25
21
59
78

36
7
17
30
19
9
4

36
18
49
68
66
33
7

167

51

164

49

158

48

173

52

78

23

131

40

122

37

* c214.11, df6, p0.03.

c272.45, df6, p0.001.

2
c 103.7, df6, p0.001.

25

Humphris et al.
TABLE 3. Psychological distress (GHQ12), emotional exhaustion
(MBI-EE) and dental environmental stress (DES16) by Dental School
Scale
dental schools

GHQ12
Cases*
N

Amsterdam
Belfast
Cork
Greifswald
Helsinki
Liverpool
Manchester
Total

31
9
10
26
3
14
18

(90)
(38)
(29)
(42)
(29)
(27)
(50)

MBI-EE
high scorers

DES16
high scorers

(%)

34
24
35
62
10
52
36

13
10
9
21
1
4
14

111 (305) 36

(%)
(98)
(39)
(35)
(46)
(29)
(25)
(58)

72 (330)

13
26
26
46
3
16
24
22

2
12
18
12
12
9
27

(%)
(98)
(38)
(34)
(44)
(29)
(24)
(55)

7
32
18
35
32
38
49

110 (322) 34

n size with base n in brackets.

* Score 3 denotes a case; c225.94, df6, p0.001.

Score 26 denotes high scorer; c226.58, df6, p0.001.

Score 38 denotes high scorer; c248.79, df6, p0.001.

exhaustion (MBI-EE) scale was completed with only

small instances of missing responses. The other two
MBI scales (i.e. depersonalisation and personal
achievement) were not analysed because the scales
contained a number of items specific to patient contact which a substantial proportion of the sample had
not experienced. The MBI-EE scale was included in
the detailed analysis. This approach is similar to the
work by Guthrie et al. (23) with Manchester first-year
medical undergraduates. Internal consistency of the
EE scale (Cronbachs alpha) was 0.81. Emotional
exhaustion was confined to 22% of the total sample
(using norms from manual). There was a significant
variation of students exhibiting emotional exhaustion
by dental school (c226.58, df6, p0.001), the lowest
and highest rates shown by Helsinki (3%) and Greifswald (46%) respectively.
Dental Environment Scale (DES). The internal consistency (Cronbachs alpha) was 0.92. Only 7% of the
Amsterdam group were included in the upper tertile
of the DES, whereas Manchester students indicated
the strongest level of stressors with nearly half (49%)
recording above the cut-off point of 38. The scale
showed considerable variation of high scorers (i.e the
number of students above the cut-off) between the
schools (c2 48.7, df6, p0.001). There was no consistent pattern of high scorers between the GHQ, MBI-EE
and DES results for each school.
The schools were divided into two groups on the
basis of patient contact. The first-year curriculum in
two schools, Cork and Greifswald, did not include patient contact, while that in the other five schools did
facilitate structured patient contact (see first-year
course
characteristics).
Psychological
distress,
emotional exhaustion and dental environmental stress

26

were higher in the students without patient contact

compared with those students who had contact
GHQ12: t2.87, df303, p0.005; MBI-EE: t5.95, df324,
p0.001; DES: t4.47, df277, p0.001 (see Table 4).
Physical health was similar between the two groups
(i.e. contact vs. no contact: t0.59, p0.5). When these
tests were controlled for gender no diminution in effect size was found.
The association of accommodation type and
psychological variables (dichotomous coding employed) was tested using chi-square. Caseness, as indicated by GHQ12 (cut off 3), was significantly associated with accommodation type (c211.02, df2,
p0.005) (see Table 5). Twenty percent of students residing with family were categorised as cases compared with 41% living away from home (CI95% of the
difference: 9.4, 33.2). Emotional exhaustion was unrelated to place of residence (c20.17, df2, p0.9),
whereas dental environmental stress was associated
(c26.22, df2, p0.05) to the place of term-time residence. Students living at home during term-time were
less stressed than those living away (23% vs. 37% respectively, CI95% of the difference: 2.3, 25.8).
No association of age, marital status or gender was
found with the psychological variables. Physical

TABLE 4. Psychological distress (GHQ12), emotional exhaustion

(MBI-EE) and dental environmental stress (DES16) by patient contact
Scale
patient contact

Contact
No contact

GHQ12
Cases*

MBI-EE
high scorers

DES16
high scorers

(%)

(%)

(%)

75 (234)
36 (71)

32
51

42 (249)
30 (81)

17
37

68 (244)
42 (78)

28
54

n size with base n in brackets.

* Score 3 denotes a case; c28.19, df1, p0.004.

Score 26 denotes high scorer; c214.58, df1, p0.001.

Score 38 denotes high scorer; c217.73, df1, p0.001.

TABLE 5. Psychological distress (GHQ12), emotional exhaustion

(MBI-EE) and dental environmental stress (DES16) by accommodation type
Scale
GHQ12
accommodation type Cases*

Lives with family

Hall of residence
or own
accommodation

MBI-EE
high scorers

DES16
high scorers

(%) N

(%) N

(%)

14 (70)
97 (235)

20
41

23
22

23
37

18 (77)
54 (251)

17 (73)
93 (249)

n size with base n in brackets.

* Score 3 denotes a case; c210.54, df1, p0.001.

Score 26 denotes high scorer; c20.12, df1, p0.5.

Score 38 denotes high scorer; c24.96, df1, p0.05.

The European Dental Student Stress Project

health was reported to be less positive in women students compared to men (mean levels: 31.73 vs. 27.02,
mean difference4.70, CI95% of the difference:
2.51,6.89, t4.23, df277, p0.001).

Discussion
The major findings of this 7-centre study were, first,
that in a recent report, the level of emotional exhaustion was higher in dental students than medical students; and, second, that general psychological distress
and course-related stress levels were associated with
the nature of the course and the immediate living conditions of the students.
A direct comparison can be made between the dental students in this study and the first-year medical
students investigated by Guthrie et al. (23) as similar
measures and cut-offs were employed. The proportion of caseness (using the GHQ12) was almost
identical between the dental (36.4%) and medical students (36.6%). However, the proportion of dental students (21.8%) with high scores on the MBI emotional
exhaustion scale was considerably higher than the
equivalent proportion of medical students (5.2%).
The difference in emotional exhaustion and the
similarity of psychological distress in the two studies
is noteworthy. The majority of the dental schools involved enabled their students to have some patient
contact, and it could be argued that the early exposure
to patients may have stimulated an increased level of
emotional fatigue. However, this explanation was not
supported by the data when the breakdown of the
schools was considered in greater detail. One of the
schools (Greifswald) concentrated on an intense programme of practicals that did not enable students to
have direct patient contact, and the level of emotional
exhaustion at this school was the highest (46%).
Rather than clinical contact, the results from Greifswald suggest another possibility to explain the variation in emotional exhaustion, namely, academic
overload. Miller (31) has put forward the hypothesis
that overwork in first-year medics may adversely affect the development of supportive relationships. Traditional courses with an emphasis on the acquisition
of facts in a competitive environment may encourage
students to strive for unattainable standards, leading
to anxiety and fatigue (32). Alternatively, it may be
that students who enter dentistry are simply more
prone to emotional exhaustion. Obviously, making
comparisons of this nature is speculative and requires
further investigation. Newton et al. (33) found in a
cross-sectional study of dental students in London
covering every year of the 5-year curriculum that the

first 2 years of the programme were the most highly

stressed. This indicates that many students had initial
difficulties coping with their undergraduate training.
Some aspects of curriculum design appeared to relate to the variation of psychological distress exhibited
by these students. As already mentioned, the possibility of patient contact having an association with
distress may be predicted from the burnout literature.
The traditional interpretation would predict that the
features of burnout would appear after a number of
years of patient contact. However, as stated previously, it has been accepted that burnout can occur
rapidly (22). Our data tends to support the view that
contact with patients is positive for students and results in lower levels of psychological distress.
Living arrangements (that is, term time accommodation) have been shown to be important in providing
support for students (34). Where students reside during term-time may be an important factor for organisers of dental courses to appreciate. Although the
wider environmental influence upon dental students
appears to be minimal (18), the influence of a home
situation appears to afford benefits to the student. The
results of the present investigation indicated that students who resided at home during term-time appeared to gain some protection against stress. The
question remains as to whether students who remain
at home are to begin with more stable or are provided
stress protection by the home environment. Furthermore, it would be of interest to investigate whether
students who are encouraged to stay at home by their
local university (as a result of subsidy rather than free
choice) may experience future difficulties. These questions can only be answered by further longitudinal
work. This future work would need to include trait
personality measurements. Nevertheless, it must be
acknowledged that advantages may accrue to students staying in their own locality. Students studying
in the dental school closest to home may be more
likely to settle in the same area. The siting of dental
schools or increasing the numbers of dentists may, in
the longer term, be linked to where new dentists are
needed (regions of high dental health need).
None of the psychological variables (distress,
emotional exhaustion or intensity of stressors) were
influenced by gender. This finding contradicts a number of previous studies (16, 35, 36). However, it is in
agreement with that of Guthrie et al. (23), who did
not demonstrate a gender effect in their 5-year longitudinal study. Gender-derived differences in dentists
may become a thing of the past. Cooper et al. (1) predicted that these differences would diminish in the
future, as women assume a more assertive role in

27

Humphris et al.

society. In a more recent cross-sectional study Wilson

et al. (5) showed gender-derived differences in dentists who had qualified for many years but not in the
more recently qualified, supporting this argument.
Some limitations of the present study are acknowledged. The response rates from individual schools
were variable and comparisons between individual
schools should be treated with caution. Every effort
was made (e.g. back translation) to ensure that the
content of the questionnaires was accurately represented in each of the four languages (Dutch, English,
Finnish and German). With those qualifications, this
study has shown that the level of psychological distress in dental students embarking on their training
is already substantial and they exhibit relatively high
levels of emotional exhaustion. The initial results of
this survey suggest a possible protective effect of early
patient contact and the home residence. In addition,
some evidence has been found that academic overload may be a negative feature with wider implications for the students overall well being. Longitudinal study of this group of students will facilitate assessing the maintenance of these effects and the prediction of psychological problems in subsequent
years.

12.
13.

14.

15.

16.
17.

18.

19.

20.
21.

22.

23.

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The European Dental Student Stress Project

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Address:
Dr Gerry Humphris
Department of Clinical Psychology
School of Health Sciences
The University of Liverpool
Whelan Building
Quadrangle
Liverpool L69 3GB
UK
e-mail: cpsy1/liverpool.ac.uk

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