INTRODUCTION

The modern concept of stress has evolved since being introduced by Hans Selye in the 1930s.1 Stress is defined as all that is unpleasant, noxious, or excessively demanding.2 The field of occupational stress is the study of those aspects of work that either have or threaten to have bad effects.3

Dentistry is usually considered a stressful profession. The stressful aspects of dental practice have been well researched.4–11 Potential effects of high levels of occupational stress in dentistry have been reported. These include hypertension,12 coronary artery disease,13 and suicide.1415 Almost one-quarter of the dentists who chose to leave the profession reported stress or burnout as their main reason for changing careers.16

Occupational stress in orthodontics has not been well researched. Some studies describing stressful aspects of dentistry have reported a number of specialists responding to the survey, but none of these report a separate analysis of the specialists' responses.17–20 Only two occupational stress studies have been found that used an orthodontic cohort. In an early study of stress among dental professionals, it was found that coronary heart disease was significantly higher in the professions judged to have the highest stress (general practice and oral surgery) than in the profession judged to have the least stress (periodontics). An intermediate prevalence of coronary heart disease was found among the orthodontic respondents.13

Restorative dentists, orthodontists, and oral surgeons in a small sample of hospital dental specialists reported comparable levels of stress. But the orthodontic cohort demonstrated less burnout than did the oral surgery or restorative groups.21 Given the low number of respondents, their age, and the hospital-based nature of their practice, it is difficult to generalize these results to the majority of orthodontic practitioners.

The objectives of this study were:

• to determine the most stressful aspects of orthodontic practice;

• to determine the most frequently occurring stressors in orthodontic practice;

• to determine the most concerning stressors in orthodontic practice, those with high severity and frequency;

• to evaluate how various personal and practice characteristics affect reports of occupational stress.

METHODS

Survey instrument

Occupational stress in orthodontic practice was evaluated using a list of potential stressors. Approximately half of these items had been reported as being stressful in general dental practice.561722 The remaining items were identified as potential stressors during a focus group meeting with three practicing orthodontists. The focus group participants included both sexes and represented a range of practice types and years of experience. A total of 67 potential stressors were included in the survey and are shown in Table 1. The potential stressors were divided into six categories: income-, patient-, referral-, staff-, time-, and work-related stressors. These categories were based on the classification system introduced by Cooper et al,4 except for referral-related stressors, which was a new category. Respondents were asked how stressful each item was (severity) and how frequently it occurred (frequency). Severity was scored using a five-point Likert-type scale with the end points “not stressful” (1) and “very stressful” (5). Frequency was scored using a five-point scale as follows: N, never; R, rarely; M, monthly; W, weekly; D, daily.

TABLE 1.  Orthodontic Occupational Stress Survey

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Another item was included to obtain an overall evaluation of occupational stress in orthodontics. The question was worded “Overall, how stressful do you find the practice of orthodontics?” Respondents were asked to use a scale from 0 (not stressful) to 100 (very stressful). This variable was considered the overall occupational stress score.

Overall job satisfaction was measured using 10 items modified from the Dentist Satisfaction Survey.23 The questions used in the overall job satisfaction survey are provided in Table 2.

TABLE 2.  Overall Job Satisfaction Survey

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Twenty-four personal and practice characteristics were addressed in the survey. Other studies had reported most of these items to affect reports of occupational stress or job satisfaction.391724 The characteristics included were age, gender, marital status, parenthood, years of professional experience, general dental experience, other specialty training, previous occupational experiences, province of practice, population of community, type of practice (solo, partnership, etc), staffing, satellite offices, part-time academic involvement, hours worked per week, weeks of vacation per year, gross income, professional affiliations (membership in the Canadian Association of Orthodontists [CAO], Fellowship in the Royal College of Dentists of Canada [FRCD(C)], diplomat status with the American Board of Orthodontists [ABO]), continuing education practices, and stress management practices.

Three practicing orthodontists acted as a test group to evaluate an initial version of the survey. Feedback from the test group was used to make minor revisions before the general distribution of the survey. This survey was part of a larger study examining occupational stress and job satisfaction among practicing orthodontists.25

RESULTS

A total of 335 responses were received for a final response rate of 51.2%. Respondents who indicated that they were not currently practicing orthodontics were excluded from the analysis. Because of this, the total number of usable responses were 319 (48.8%). The response rate from Quebec (57/129 or 44.2%) was mildly lower than the national average, despite the survey having not been translated into French. Therefore, it is reasonable to assume that the results from this sample are representative of orthodontists practicing in Canada. A summary of selected characteristics of the respondents is presented in Table 3.

TABLE 3.  Key Descriptive Data of Survey Respondents^a

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Thirteen data entry errors were found in 14,656 data points for a rate of 0.089%. The remaining 80% of the surveys were not checked because of this low data entry error rate.

Evaluation of potential stressors

A wide range of responses to the potential stressors were found. Each of the 67 items had a range of severity scores from 1 to 5. The most stressful aspects of orthodontic practice, based on mean severity scores, are presented in Table 4. The most frequent stressors in orthodontic practice, based on mean frequency scores, are presented in Table 5. Most of the highly scored stressors received low frequency scores. The frequency score for the most stressful item, the patient shows dissatisfaction with the care received, was only 1.99 (SD = 0.41), ranking this item 62 out of 67 on the basis of frequency. Similarly, most of the frequent stressors had low severity scores. The most frequent stressor, managing adult patients, had a mean severity score of 2.50 (SD = 0.96), ranking 47 out of 67. The stressor, patients being late for or missing adjustment appointments, had a mean severity score of 2.71 (SD = 1.09), ranking 34 out of 67.

TABLE 4.  Rank Order of Potential Stressors Based on Mean Severity Score^a

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TABLE 5.  Rank Order of Potential Stressors Based on Mean Frequency Score^a

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Five items had mean severity and frequency scores equal to or greater than 3.0. These items were considered the most concerning stressors in orthodontic practice and are presented in Table 6.

TABLE 6.  Most Concerning Stressors in Orthodontics. Stressors with mean severity and mean frequency scores equal to or greater than 3.0^a

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Mean category scores for the six categories of stressors are presented in Table 7. The category with the highest mean score was “time-related” stressors. Paired t-tests showed this category score to be significantly higher (P = .004) than all other category scores. No statistically significant difference was found between the next highest categories: “staff-” and “patient-related” stressors. Also, no significant difference was found between the two categories with the lowest scores: “income-” and “referral-related” stressors. Differences between the categories were small compared with the variance within the categories.

TABLE 7.  Mean Category Scores for the Six Categories of Stressors^a

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Factors affecting occupational stress

“Overall occupational stress scores” ranged from 0 to 99 with a mean of 49.3 (SD = 25.5). The scores were relatively uniformly distributed across the range.

Individual analysis revealed seven characteristics with significant effects (P < .05) on overall occupational stress scores. Three of these characteristics were positively related to reports of occupational stress: part-time academics (r = 0.12), hours worked per week (r = 0.18), and participation in a study club (r = 0.14). The remaining characteristics were negatively associated with reported occupational stress: age (r = −0.19), years of practice (r = −0.16), weeks of vacation per year (r = −0.19), and reported overall job satisfaction (r = −0.15).

Stepwise multiple regression analysis revealed a seven-component model that predicted 35.9% of the variation in overall occupational stress scores (Table 8).

TABLE 8.  Stepwise Multiple Regression for overall occupational stress scores^a

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DISCUSSION

Over half of orthodontists in Canada responded to the survey. The descriptive data indicate that a broad spectrum of practice and personal characteristics were represented.

Analysis of the potential stressors revealed 24 items that received a mean severity score of 3.0 or greater. Many similarities are seen between our results and those reported for general dentistry.

The three most highly scored stressors, the patient shows dissatisfaction with the care received, performing clinical tasks on a difficult or uncooperative patient, and falling behind schedule, were almost identical to the three most highly scored stressors reported by Bourassa and Baylard,5 viz, the patient shows dissatisfaction with the care he has received, giving care to an uncooperative patient, and being behind schedule. These three issues are also among the most highly ranked in other studies.617 Other stressors that are similar in orthodontics and dentistry are staffing issues, idealism, patients missing appointments, financial burdens, and being overworked.

Some issues often reported as being stressful in general dentistry were not found to be highly stressful in an orthodontic population. These include “causing pain in patients” and “proceeding to a difficult, unexpected operation.”

Many more issues, however, were scored as highly stressful in the orthodontic population, but these have not appeared frequently in dental studies. These include the following: dealing with unrealistic patient expectations, relapse in retention patients, pressure to debond from patient and/or parent, general practitioners questioning case management, managing “burnt-out” patients, and motivating patients with poor OH and/or decalcification. Thus, the orthodontists experience stress associated with their particular specialty as well as with general practice-related issues.

Only five items received mean severity and frequency scores of 3.0 or greater and were considered the most concerning stressors in orthodontic practice. This definition was chosen because these items should be considered stressful by most orthodontists and should occur more frequently than once a month. An issue considered as one of the most concerning aspects of orthodontic practice is “motivating patients with poor OH and/or decalcification.” This issue emphasizes the importance of patients' cooperation during their treatment. Also, it shows the desire of the orthodontists to improve their patients' smiles rather than to accept the undesirable consequences of poor hygiene during treatment.

Four of the most concerning stressors are time-management issues. Treating “patients with broken appliances” causes “time pressures” that interfere with “trying to keep to a schedule,” causing clinicians to “fall behind schedule.”

Mean category scores for the six classes of orthodontic stressors also show the importance of time management in orthodontics. Although the differences between the groups were small, stressors categorized as time related had higher mean severity scores. The results suggest that clinicians interested in decreasing occupational stress should first consider ways to improve their time-management skills.

An issue that must be considered when reviewing the results of this survey is the amount of variation in the responses. Pronounced differences were seen in response to the severity of the 67 potential stressors. Each item was scored as “very stressful” by at least one orthodontist and as “not stressful” by at least one other. In most cases the variance within responses to an item is smaller than the differences between items. On the basis of current stress research, this variance is to be expected. Personality and individual differences are known to have important influences on the stress response.2 The severity score standard deviations in this study are similar to those reported in other studies on dental stressors.22 Perhaps the influence of personality and individual differences is most “evident in overall occupational stress scores.” The range of responses nearly spanned the full 100-point scale of the question, and the standard deviation was over a quarter of the response scale.

Analysis of personal and practice characteristics attempted to explain some of the variation in “overall occupational stress scores.” Individual analyses identified several factors with significant effects on overall occupational stress. Age, years of experience, and hours worked per week were significantly related to “overall occupational stress.” These characteristics have also been reported to affect reports of occupational stress in dentistry.51724 The reported correlation coefficients between these characteristics and reports of occupational stress in dentistry are remarkably similar to those found in orthodontics. The strongest correlation was between “overall occupational stress” and “overall job satisfaction.” This correlation has also been previously reported in the dental literature.242627 Two factors significantly related to “overall occupational stress scores” had not been previously reported, viz, part-time academics and participation in a study club. These items, however, were not included in the previous studies. Evidence of part-time academics and participation in a study club being related to the reported occupational stress is also found in the multiple regression analysis. Both these items, as well as age, hours worked per week, and “overall job satisfaction,” were included in the final regression model. Increased days of continuing education was also associated with a decreased report of occupational stress. Interestingly, participation in stress management was associated with increased reports of occupational stress. It is reasonable to assume that these individuals were more aware of stress and, therefore, more likely to be taking steps to manage stress.

Overall, the final regression model was only able to account for approximately one-third of the variation in the “overall occupational stress scores.” Therefore, “overall occupational stress” is influenced more by other factors, such as personality, than by the combined effects of the characteristics identified in this survey.

CONCLUSIONS

Large variation is found in the evaluation of potential stressors and overall occupational stress in orthodontics.

The most concerning stressors in orthodontics, based on high severity and frequency of occurrence, involve time management and cooperation of the patient.

The stressors in orthodontic practice are similar to those in dentistry, but some stressors unique to the orthodontic profession do exist.

Multiple regression analysis identified a model, including overall job satisfaction, age, participation in a study group, hours worked per week, part-time academics, days of continuing education per year, and participation in stress management, to account for 35.9% of the variation in reported occupational stress.

Other factors seem to have a greater effect on reported occupational stress than do the characteristics evaluated by this survey.