Risk analysis of factors in clinical anxiety among undergraduate and postgraduate students in dentistry

Abstract

BACKGROUND:

When anxiety is persistent among dental students, the consequence could be poor academic performance, ill health, lack of empathy, and exhaustion.

OBJECTIVE:

This study aimed to determine the level of anxiety along with anxiety-provoking factors among clinical dental students.

METHODS:

This study included dental undergraduate and postgraduate clinical students from a public university. A modified version of the self-administered Moss and McManus questionnaire, which consisted of 50 items, was utilized to evaluate the levels of anxiety. The results were analyzed using SPSS^® version 24. The significance level was set at p < 0.05.

RESULTS:

Within 180 participants, 140 (77.77%) were undergraduate students, while 40 (22.22%) were postgraduate dental students. Overall, the top clinical anxiety-provoking factor included failure to pass the final examination, whereas the least clinical anxiety-provoking element was communicating with the opposite gender. Significant differences existed among male and female participants in the seven anxiety-provoking factors among the participants namely dealing with elderly patients, fail to pass finals, arresting post-extraction bleeding, patients asking difficult questions, fear of accidental pulp exposure, dealing with a child or non-cooperative patient, and fear of taking an incorrect impression. Postgraduate students showed lower anxiety scores in various clinical tasks as compared to undergraduate students.

CONCLUSIONS:

Postgraduate dental students share largely the same perspectives with undergraduate dental students on the clinical anxiety-provoking situations with slight variations. Being the future healthcare providers, dental students must learn techniques to help them manage their dental anxiety and fear as well as deal with anxiety related to treating patients

Keywords

Clinical anxiety dental students postgraduate undergraduate

1 Introduction

Anxiety is a multisystem reaction to a perceived danger or threat [1]. A significant fraction of human anxiety is induced by the anticipation of future incidents [2]. However, generalized anxiety is excessive worry about several things such as personal health, work, social interactions, and everyday routine life circumstances [3]. According to the World Health Organization, 264 million (3.6%) people suffer from anxiety disorder globally, making it one of the major reasons for disability and lost health [4]. Among college students on American campuses, around 1 in 3 students meet the criteria for a clinically considerable mental health problem [5]. Based on the outcomes of data gathered over 10 years via the Health Minds Study, an annual investigation consisting of 155,026 students from 196 campuses, the treatment rate for mental health among the college cohort hiked to 34% in 2017 from 19% in 2007 [6].

Dental school is a phase of severe psychological distress with an unintentional negative impact on the mental health of students, with a high prevalence of stress, depression, and anxiety in dental students [7]. The changeover from preclinical to clinical stages of dental education with challenges regarding patients, trainers, and paraprofessionals may be stressful [8 –10]. Additionally, these are the performance of dental procedures on patients and are established to trigger anxiety, otherwise known as “Clinical anxiety” in this study. Studies have reported that students under a high level of stress always were emotionally exhausted and suffered from physical manifestations, psychological distress, and, eventually, burnout [11]. Therefore, few types of research have been conducted on dental students in different countries focusing on anxiety levels during their learning as well as training stage [12 –14].

Interestingly, a systematic review has also associated the perception of anxiety with the academic year, sex, race, and living atmosphere [15]. According to Polychronopoulou et al. [11], dental students are continuously stressed as they need to be proficient in both clinical and academic aspects, along with interpersonal skills. They reported that anxiety was significantly linked to sex, type of curriculum, educational fees, level of study, and class size. Similarly, a study concluded that fear of failure is the top anxiety-provoking factor throughout clinical training among undergraduate dental students [16]. Between sexes, studies in Saudi Arabia, Japan, and Europe have reported that male students had fewer anxiety scores than female students, whereas Indian research did not find any difference [11 , 15–17]. Given the literature, it is critical to have a better understanding of students’ perceived anxiety-provoking factors, which would, in turn, lead to constructing effective and positive learning and training environment.

Anxiety and stress among clinical dental students are reported higher as compared to peers in the general population as per studies performed in many countries [18]. Basudan et al. [18] reported abnormal levels of stress, anxiety, and depression identified in 54.7%, 66.8%, and 55.9% of the research participants, respectively [18]. A study conducted among Spanish dental students in 2014 compared suicide ideation, depression, and burnout among 2nd, 4th, and 5th year dental students [19]. Compared to 5th year dental students, 2nd and 4th year dental students demonstrated a double amount of burnout. They also encountered a triple amount of suicide ideation and depression in comparison with their 5th year classmates. The highest suicide ideation was reported among 4th year dental students [19]. According to Rada and Johnson-Leong [20], students drawn to dentistry tend to have unnecessarily high standards of performance, unrealistic expectations, compulsive personalities, and require social status and approval. The process of striving for perfection could create results opposite of the intended outcomes and obstruct performance by causing self-criticism, inefficient time management, and fatigue [21].

Unfortunately, high levels of anxiety among clinical dental students often continue into practice resulting in burnout and less than optimal patient care among practitioners [18]. Identifying the sources of anxiety as well as addressing strategies for its reduction is essential for improving dental education [18]. Several studies have been performed to evaluate the anxiety-provoking factors among nursing and medical students; however, there is a shortage of literature related to clinical anxiety-provoking situations among dental students [8–10 , 22]. Therefore, this study aimed to determine the level of anxiety along with anxiety-provoking factors among clinical dental students.

2 Methods

2.1 Study design and ethical considerations

This cross-sectional study was conducted among Year 3 to Year 5 undergraduate and Year 1 to Year 4 postgraduate dental students from a public Malaysian university. The identities of the students remained anonymous and their participation was completely voluntary. This study was submitted to and approved by Human Ethics Review Committee of University Sains Malaysia, Malaysia.

2.2 Research tool

A self-administered Moss and McManus questionnaire [23] was utilized, which is a validated and most used tool and has been previously utilized in several studies with similar objectives [1 , 24]. To encompass dental-specific perceived sources of anxiety, the questionnaire was slightly modified. It consisted of 50 questions with 38 questions from the original document and 12 added questions. A 4-point Likert scale for scoring (not anxious, slightly anxious, fairly anxious, and very anxious) was used to assess the situations. The scoring was from 1 (not anxious) to 4 (very anxious), making minimum and maximum anxiety scores of 50 and 200, respectively. The lower score indicated lower clinical anxiety, and the higher score indicated higher clinical anxiety.

2.3 Participants and data collection

The questionnaire was hand distributed among all the participating clinical undergraduate dental students (3rd, 4th, and 5th year) and clinical postgraduate dental students at a public university in Malaysia between November and December 2019. The absentees and those who were not willing to participate were excluded. No incentive was offered, and the participation was voluntary. The questionnaire, being a self-administered anonymous questionnaire, had no identifiers. The pre-test of the questionnaire was performed on 15 dentists who finished their internship within the last six months.

2.4 Data analysis

The reliability (internal consistency) was identified utilizing Cronbach’s alpha, and the items suggested by Statistical Package for the Social Sciences (version 24.0; IBM Corp., Armonk, NY, USA) to increase coefficients were removed. Then, the authors recorded an individual total score for each study participant by adding up scores on the items. The data were subjected to descriptive and parametric statistics (one-way ANOVA, Bonferroni post hoc, and independent T-test). The situations recorded among the participants as not anxious, slightly anxious, fairly anxious, and very anxious were translated as none, mild, moderate, and severe clinical anxiety conditions. All data are expressed as mean±standard deviation (SD). For all tests, statistically significant differences were set at p < 0.05.

3 Results

A total of 208 students met the inclusion criteria; however, only 186 of them participated. Out of these participants, 180 of them filled the questionnaire, which was eventually used for this study. Clinical undergraduate dental students constituted 77.77% (140/180) of the participants, and clinical postgraduate dental students represented 22.22% (40/180) of the participants. Most of the participants were female students, 55.80% (101/180) (Fig. 1A). Most participants had Malay ethnicity of 51.66% (93/180) followed by Chinese 29.44% (53/180) and Indian ethnicity 13.33% (24/180) (Fig. 1B).

Fig. 1

A. Presenting the number of dental students as per the academic year in dental school and level of education (Undergraduate and postgraduate). B. Presenting number of students based on their ethnicity and academic year.

Among the participants, the overall prevalence of clinical anxiety was 98.3% (177/180) (Fig. 2). The top 10 anxiety-provoking factors failed to pass finals 2.26 (0.70), telling consultant I do not know anything 2.25 (0.73), presenting a case to professor 2.23 (0.70), helping faint episode 2.19 (0.66), fear of bracket removal 2.17 (0.77), arresting post-extraction bleeding 2.10 (0.74), wrong bracket positioning 2.02 (0.83), root canal treatment failure 1.99 (1.01), dealing with psychiatric patient 1.97 (0.76), and failure of denture retention 1.87 (0.81). The ten least clinical anxiety-provoking factors were communicating with opposite gender 0.11 (0.30), fear of extracting wrong tooth 0.58 (0.60), using ultra-high-speed handpiece 0.66 (0.61), talking to the attendant about patient 0.67 (0.64), fear of getting infected by patient 0.68 (0.56), wrong patient positioning 0.68 (0.67), dealing with elderly patients 0.72 (0.62), telling patient I do not know something 0.78 (0.56), performing intra-oral examination 0.78 (0.69), and getting up early for case 0.78 (0.72) (Table 1). Significant differences existed among male and female participants in the seven anxiety-provoking factors among the participants namely dealing with elderly patients (p = 0.002), fail to pass finals (p = 0.01), arresting post-extraction bleeding (p = 0.01), patients asking difficult questions (p = 0.02), fear of accidental pulp exposure (p = 0.04), dealing with a child or non-cooperative patient (p = 0.05), and fear of taking an incorrect impression (p = 0.05) (Table 2). Overall, Cronbach’s alpha was 0.890 for undergraduate dental students and 0.731 for postgraduate dental students.

Fig. 2

Presenting anxiety levels among the dental students divided on the basis of level of dental education.

Table 1

Mean scores of anxiety provoking situations among the participants

Sr. No	Characteristics	Mean	SD
1	Making a diagnosis	0.83	(0.55)
2	Getting diagnosis wrong	0.81	0.580
3	Unable to defend diagnosis	1.69	0.83
4	Telling consultant, I do not know anything	2.25	0.731
5	Telling patient, I do not know something	0.78	0.565
6	Presenting case to professor	2.23	0.702
7	Carelessly hurting patient	1.14	0.885
8	Suturing patient	1.36	0.824
9	Tackling abusive drunk patient	1.61	0.728
10	Getting infected by patient	0.68	0.566
11	Performing intraoral exam	0.78	0.695
12	Patient asking difficult questions	0.91	0.735
13	Dealing with child or non-cooperative patient	1.35	0.835
14	Administering local anesthesia	1.67	0.914
15	Being left alone to tackle difficult patient	1.19	0.756
16	Talking to attendant about patient	0.67	0.641
17	Getting up early for case	0.78	0.721
18	Being up all night	0.79	0.640
19	Going to operation theatre	1.14	0.785
20	Dealing with elderly patient	0.72	0.628
21	History taking	1.84	0.904
22	Holding extraction forecep	1.36	0.925
23	Arresting post-extraction bleeding	2.10	0.748
24	Helping faint episode	2.19	0.669
25	Fracturing tooth	1.67	0.797
26	Using ultra-highspeed handpiece	0.66	0.610
27	Accidental pulp exposure	1.25	0.945
28	Extracting wrong tooth	0.58	0.606
29	Improper radiograph	1.46	0.779
30	Wrong radiograph interpretation	1.49	0.836
31	Senior checking post-scaling calculus	1.66	0.734
32	Short attendance	1.41	0.837
33	Short quota	1.58	0.754
34	Fail to pass test	1.72	0.784
35	Fail to pass finals	2.26	0.702
36	Trauma gingiva	1.37	0.708
37	Fear patient satisfaction	1.62	0.703
38	Dealing with psychiatric patient	1.97	0.762
39	Treating medically compromised patient	1.56	0.756
40	Dealing with special people	1.61	0.744
41	Giving wrong treatment	1.74	0.765
42	Failure of denture retention or fitting	1.87	0.812
43	Incorrect impression	1.81	0.870
44	Fear of bracket removal	2.17	0.773
45	Wrong bracket position	2.02	0.835
46	Wrong dental chair position	0.91	0.674
47	Wrong patient position	0.68	0.672
48	Over preparation of cavity	1.81	0.968
49	Root canal treatment failure	1.99	1.017
50	Communicate with opposite sex	0.11	0.308

Table 2

Comparison of mean anxiety scores of male and female participants using independent T test

Sr. No	Characteristics	Male	Female	P-value
1	Making a diagnosis	0.85 (0.55)	0.81 (0.56)	0.66
2	Getting diagnosis wrong	0.85 (0.48)	0.77 (0.64)	0.36
3	Unable to defend diagnosis	1.59 (0.85)	1.76 (0.81)	0.18
4	Telling consultant, I do not know anything	2.35 (0.69)	2.17 (0.74)	0.08
5	Telling patient, I do not know something	0.80 (0.54)	0.76 (0.58)	0.67
6	Presenting case to professor	2.29 (0.73)	2.19 (0.67)	0.33
7	Carelessly hurting patient	1.11 (0.96)	1.17 (0.82)	0.68
8	Suturing patient	1.35 (0.81)	1.37 (0.83)	0.92
9	Tackling abusive drunk patient	1.57 (0.76)	1.64 (0.70)	0.50
10	Getting infected by patient	0.66 (0.61)	0.69 (0.52)	O.68
11	Performing intraoral exam	0.80 (0.70)	0.77 (0.69)	0.81
12	Patient asking difficult questions	0.77 (0.73)	1.02 (0.72)	0.02
13	Dealing with child or non-cooperative patient	1.22 (0.84)	1.46 (0.81)	0.05
14	Administering local anesthesia	1.61 (0.91)	1.72 (0.91)	0.40
15	Being left alone to tackle difficult patient	1.19 (0.80)	1.20 (0.72)	0.94
16	Talking to attendant about patient	0.59 (0.61)	0.73 (0.66)	0.14
17	Getting up early for case	0.73 (0.72)	0.81 (0.71)	0.47
18	Being up all night	0.82 (0.65)	0.77 (0.63)	0.60
19	Going to operation theatre	1.11 (0.73)	1.17 (0.82)	0.64
20	Dealing with elderly patient	0.56 (0.54)	0.84 (0.65)	0.002
21	History taking	1.82 (0.91)	1.85 (0.89)	0.83
22	Holding extraction forecep	1.29 (1.00)	1.41 (0.86)	0.41
23	Arresting post-extraction bleeding	2.25 (0.75)	1.98 (0.72)	0.01
24	Helping faint episode	2.16 (0.66)	2.22 (0.67)	0.59
25	Fracturing tooth	1.61 (0.80)	1.72 (0.78)	0.33
26	Using ultra-highspeed handpiece	0.58 (0.67)	0.71 (0.55)	0.16
27	Accidental pulp exposure	1.09 (0.90)	1.38 (0.95)	0.04
28	Extracting wrong tooth	0.62 (0.62)	0.55 (0.59)	0.47
29	Improper radiograph	1.37 (0.71)	1.53 (0.81)	0.14
30	Wrong radiograph interpretation	1.48 (0.86)	1.50 (0.82)	0.91
31	Senior checking post-scaling calculus	1.71 (0.73)	1.62 (0.73)	0.44
32	Short attendance	1.37 (0.83)	1.44 (0.84)	0.58
33	Short quota	1.62 (0.80)	1.55 (0.71)	0.56
34	Fail to pass test	1.82 (0.78)	1.64 (0.78)	0.12
35	Fail to pass finals	2.41 (0.70)	2.14 (0.67)	0.01
36	Trauma gingiva	1.35 (0.71)	1.38 (0.70)	0.83
37	Fear patient satisfaction	1.62 (0.64)	1.61 (0.74)	0.95
38	Dealing with psychiatric patient	1.91 (0.81)	2.01 (0.71)	0.39
39	Treating medically compromised patient	1.91 (0.81)	1.54 (0.75)	0.74
40	Dealing with special people	1.59 (0.80)	1.61 (0.69)	0.86
41	Giving wrong treatment	1.70 (0.75)	1.77 (0.77)	0.50
42	Failure of denture retention or fitting	1.94 (0.82)	1.82 (0.80)	0.34
43	Incorrect impression	1.67 (0.90)	1.92 (0.83)	0.05
44	Fear of bracket removal	2.14 (0.79)	2.19 (0.75)	0.67
45	Wrong bracket position	1.99 (0.82)	2.04 (0.84)	0.67
46	Wrong dental chair position	0.89 (0.67)	0.92 (0.67)	0.73
47	Wrong patient position	0.73 (0.67)	0.64 (0.67)	0.37
48	Over preparation of cavity	1.80 (0.99)	1.82 (0.95)	0.86
49	Root canal treatment failure	2.03 (1.01)	1.97 (1.02)	0.71
50	Communicate with opposite sex	0.06 (0.24)	0.14 (0.34)	0.09

Mean anxiety scores among clinical undergraduate dental students (3rd, 4th, and 5th year), as well as clinical postgraduate dental students, were also compared using One-way ANOVA (Table 2) and Bonferroni post hoc test (Table 3), with postgraduate students showing lower anxiety scores in various clinical tasks as compared to undergraduate students (p < 0.05), except when telling consultant that they do not know anything, presenting a case to the professor and carelessly hurting patient (p < 0.05). Undergraduate students particularly 3rd year students had higher anxiety scores in clinical domains like defending a diagnosis, dealing with a child or non-cooperative patient, administering local anesthesia, accidental pulp exposure, extracting a wrong tooth, wrong radiograph interpretation, dealing with special people, wrong patient position, over the preparation of cavity and communicating with the opposite sex. 4th year students showed significantly higher anxiety scores only while taking incorrect impressions. Final year students showed higher anxiety scores when the patient asked difficult questions, dealing with psychiatric patients dealing with root canal treatment failure.

Table 3

Comparison of mean anxiety scores between year of the student using One-way ANOVA

Sr. No	Characteristics	3rd year	4th year	5th year	Postgraduate	P value
1	Making a diagnosis	0.82 (0.59)	0.91 (0.58)	0.90 (0.53)	0.65 (0.48)	0.110
2	Getting diagnosis wrong	0.84 (0.57)	0.77 (0.52)	0.86 (0.56)	0.75 (0.67)	0.772
3	Unable to defend diagnosis	1.84 (0.70)	2.17 (0.70)	1.79 (0.56)	0.83 (0.74)	0.000
4	Telling consultant, I do not know anything	2.16 (0.73)	2.19 (0.74)	2.07 (0.74)	2.63 (0.58)	0.002
5	Telling patient, I do not know something	0.80 (0.56)	0.89 (0.56)	0.86 (0.56)	0.53 (0.50)	0.011
6	Presenting case to professor	2.00 (0.69)	2.15 (0.65)	2.29 (0.67)	2.58 (0.67)	0.001
7	Carelessly hurting patient	0.88 (0.65)	0.87 (0.67)	0.79 (0.64)	2.18 (0.81)	0.000
8	Suturing patient	1.49 (0.61)	1.77 (0.66)	1.69 (0.71)	0.38 (0.49)	0.000
9	Tackling abusive drunk patient	1.84 (0.67)	1.66 (0.66)	1.79 (0.68)	1.08 (0.65)	0.000
10	Getting infected by patient	0.80 (0.56)	0.77 (0.56)	0.76 (0.53)	0.33 (0.47)	0.000
11	Performing intraoral exam	0.98 (0.64)	0.94 (0.67)	0.93 (0.71)	0.20 (0.40)	0.000
12	Patient asking difficult questions	0.98 (0.67)	0.98 (0.70)	1.10 (0.69)	0.55 (0.78)	0.004
13	Dealing with child or non-cooperative patient	1.51 (0.50)	1.77 (0.66)	1.74 (0.70)	0.25 (0.43)	0.000
14	Administering local anesthesia	2.14 (0.77)	1.72 (0.71)	1.93 (0.74)	0.75 (0.80)	0.000
15	Being left alone to tackle difficult patient	1.37 (0.48)	1.60 (0.64)	1.45 (0.59)	0.23 (0.42)	0.000
16	Talking to attendant about patient	0.75 (0.59)	0.89 (0.52)	0.88 (0.73)	0.10 (0.304)	0.000
17	Getting up early for case	0.92 (0.62)	1.06 (0.81)	0.95 (0.58)	0.08 (0.267)	0.000
18	Being up all night	0.96 (0.56)	1.06 (0.56)	0.90 (0.56)	0.08 (0.267)	0.000
19	Going to operation theatre	1.33 (0.73)	1.09 (0.58)	1.43 (0.91)	0.68 (0.694)	0.000
20	Dealing with elderly patient	0.90 (0.64)	0.77 (0.56)	0.95 (0.58)	0.18 (0.385)	0.000
21	History taking	1.98 (0.78)	1.98 (0.73)	2.45 (0.59)	0.85 (0.700)	0.000
22	Holding extraction forecep	1.53 (0.70)	1.74 (0.76)	1.81 (0.77)	0.20 (0.405)	0.000
23	Arresting post-extraction bleeding	1.94 (0.73)	2.21 (0.75)	2.05 (0.69)	2.23 (0.800)	0.196
24	Helping faint episode	2.27 (0.63)	2.26 (0.64)	2.19 (0.63)	2.03 (0.768)	0.299
25	Fracturing tooth	1.98 (0.70)	2.13 (0.71)	1.24 (0.43)	1.20 (0.823)	0.000
26	Using ultra-high speed handpiece	0.65 (0.59)	0.94 (0.52)	0.90 (0.57)	0.08 (0.267)	0.000
27	Accidental pulp exposure	1.29 (0.92)	1.87 (0.79)	0.62 (0.69)	1.13 (0.911)	0.000
28	Extracting wrong tooth	0.67 (0.58)	0.81 (0.61)	0.74 (0.58)	0.05 (0.221)	0.000
29	Improper radiograph	1.61 (0.72)	1.68 (0.72)	1.64 (0.75)	0.83 (0.594)	0.000
30	Wrong radiograph interpretation	1.63 (0.72)	1.72 (0.74)	1.76 (0.69)	0.75 (0.809)	0.000
31	Senior checking post-scaling calculus	1.55 (0.73)	1.57 (0.71)	1.71 (0.74)	1.85 (0.736)	0.194
32	Short attendance	1.59 (0.72)	1.62 (0.73)	1.74 (0.73)	0.58 (0.636)	0.000
33	Short quota	1.57 (0.70)	1.68 (0.72)	1.64 (0.727)	1.43 (0.874)	0.421
34	Fail to pass test	1.47 (0.70)	1.60 (0.71)	1.52 (0.707)	2.40 (0.672)	0.000
35	Fail to pass finals	2.10 (0.70)	2.19 (0.68)	2.12 (0.670)	2.68 (0.616)	0.000
36	Trauma gingiva	1.25 (0.52)	1.45 (0.65)	1.48 (0.671)	1.30 (0.966)	0.360
37	Fear patient satisfaction	1.76 (0.81)	1.55 (0.58)	1.40 (0.627)	1.73 (0.716)	0.059
38	Dealing with psychiatric patient	2.16 (0.61)	2.13 (0.64)	2.12 (0.670)	1.38 (0.868)	0.000
39	Treating medically compromised patient	1.43 (0.64)	1.43 (0.58)	1.64 (0.656)	1.80 (1.067)	0.056
40	Dealing with special people	1.80 (0.63)	1.81 (0.57)	1.83 (0.581)	0.88 (0.757)	00.000
41	Giving wrong treatment	1.71 (0.72)	1.62 (0.73)	1.62 (0.697)	2.05 (0.846)	.029
42	Failure of denture retention or fitting	1.90 (0.78)	1.91 (0.74)	1.93 (0.745)	1.73 (0.987)	0.637
43	Incorrect impression	2.06 (0.73)	2.02 (0.73)	2.02 (0.749)	1.03 (0.862)	0.000
44	Fear of bracket removal	2.10 (0.75)	2.51 (0.71)	2.05 (0.731)	1.98 (0.800)	0.004
45	Wrong bracket position	2.12 (0.73)	2.17 (0.76)	2.14 (0.751)	1.58 (0.984)	0.002
46	Wrong dental chair position	1.08 (0.71)	0.98 (0.64)	0.98 (0.680)	0.53 (0.506)	0.001
47	Wrong patient position	0.92 (0.59)	0.74 (0.73)	0.67 (0.721)	0.33 (0.474)	0.002
48	Over preparation of cavity	2.12 (0.79)	2.13 (0.79)	2.14 (0.718)	0.70 (0.758)	0.000
49	Root canal treatment failure	2.41 (0.75)	2.32 (0.75)	2.17 (0.794)	0.90 (1.033)	0.000
50	Communicate with opposite sex	0.14 (0.34)	0.11 (0.31)	0.10 (0.297)	0.08 (0.267)	0.000

4 Discussion

The present study investigated the level of anxiety along with anxiety-provoking factors among clinical postgraduate and undergraduate dental students at a public institution in Malaysia, using the Moss and McManus questionnaire. The overall prevalence of clinical anxiety was significant, with over 60% of participants showing moderate clinical anxiety levels. Undergraduate students, notably the final year students, showed prominent anxiety levels compared with postgraduate students, while minorities showing a severe level of anxiety. Previous studies in medical and dental students have agreed to the fact that undergraduate students are more prone to anxiety and depression due to numerous factors like peer pressure, study load, genetic predisposition, failure to pass annual exams, dealing with psychiatric patients, getting the wrong diagnosis to name the few [1 , 26]. Similarly, a survey conducted on dental students in Bangalore, India, has shown clinical anxiety in undergraduate students; however, there was no significant difference between age or year of study [27].

In this study, the most common anxiety-provoking factors in both undergraduate and postgraduate students were: failure to pass finals, which is in agreement with the outcome of a study conducted among final year dental students of the University of Benin, Nigeria [1]; and in contrast to the findings of a study performed among dental students at the Faculty of Dentistry, University of Otago, New Zealand, which reported “getting the diagnosis wrong” as the highest clinical anxiety-provoking factor [28]. Moreover, postgraduate students showed consistently lower anxiety showing scores in various clinical tasks as compared to undergraduate students. It is generally perceived that postdoctoral trainees have increased awareness, detailed understanding, and more clinical experience regarding the handling of the patients compared to junior students [29]. Our findings also depicted that postgraduate students showed higher mean anxiety scores when telling a consultant that they do not know anything, presenting a case to the professor, and carelessly hurting the patient.

The five year curriculum at Universiti Sains Malaysia is structured such that first, second, and third year students have mostly preclinical and academic teaching, with limited experience of the treatment of patients, which commences in the third year. In the fourth and fifth years, all modules have clinical components. But the most important aspect noticed in this study was that there was a similarity in the level of anxiety amongst dental undergraduate and postgraduate students regarding the most threatening and complex dental situations like suturing patients, getting infected by a patient, improper radiograph, dealing with elderly and medically compromised patients, arresting post-extraction bleeding, helping faint episode, fracturing a tooth, giving wrong treatment, failure of denture retention, incorrect impression, fear of bracket removal and wrong However, it was noted in few dental situations that undergraduate students particularly 3rd and 4th year students had higher anxiety scores while defending a diagnosis, dealing with a child or non-cooperative patient, administering local anesthesia, accidental pulp exposure, extracting the wrong tooth, wrong radiograph interpretation, dealing with special people, wrong patient position, over the preparation of cavity, communicating with the opposite sex and taking incorrect impressions. Final year students showed higher anxiety scores when the patient asked difficult questions, dealing with psychiatric patients dealing with root canal treatment failure. A survey conducted in Saudi Arabia highlighted almost similar anxiety-provoking factors among undergraduate dental students [28]. There might be a possibility that junior students lack clinical exposure and confidence when dealing with patients [26, 28].

Although there was no significant gender difference in clinical anxiety, however, male participants experienced more anxiety in only 2/50 situation: while telling a consultant that they don’t know anything and failing to pass finals whereas female participants showed significant anxiety levels in few situations like when patients asked difficult questions, dealing with non-cooperative patients, arresting post-extraction bleeding, fear of accidental pulp exposure, fear of taking an incorrect impression and interacting with the opposite sex. These findings contrast with previous studies indicating the fact that males are more capable of positively enduring stressful situations [15, 30]. Literature also shows that there is a difference between the preclinical and clinical years. Preclinical stress affects females more than males, bracket position. This can be explained by the fact that dental clinical students in Universiti Sains Malaysia are somewhat fully prepared and trained by suitable courses before they would have started their clinical work.

In the present study, none of these gender differences was observed, which is a reflection of the growing reputation of female students as being equal to or better than male students in a traditionally male-dominated society [13]. However, females recorded more stress while dealing with patients and interacting with male faculty members or students. These findings might be due to the cultural and social upbringing of the students, which influences their behaviour during their interaction with patients, faculty members, and particularly the opposite sex. Although this study is limited by population size, it may be considered as necessary baseline information that could facilitate comparison with other research and from which larger-scale studies may be modelled. Another limitation is that it was a uni-centered survey, and hence it might not reflect the anxiety-provoking factors of students in other dental institutions. Furthermore, most of the students had Malay ethnicity (51.6%); therefore, these findings may not be generalizable to students of other ethnicities.

5 Conclusions

Postgraduate dental students share largely the same perspectives with undergraduate dental students on the clinical anxiety-provoking situations with slight variations. Being the future healthcare providers, the dental students must learn techniques to help them manage their dental anxiety and fear as well as deal with anxiety related to treating patients.

Footnotes

Acknowledgment

The authors are grateful to the Deanship of Scientific Research, King Saud University for funding through Vice Deanship of Scientific Research Chairs, Research Chair for Biological Research in Dental Health.

Author contributions

PA, AC and JA: Conceptualization, Methodology, Supervision, Investigation, Software, Data curation, Writing - original draft. EA, MA and KA: Investigation, Questionnaire design and distribution, Data curation, Writing and revision of manuscript. TA, AA and FA: Questionnaire design, Questionnaire validity, Data curation, Manuscript writing, Data collection, Data analyses, Data inference.

Conflict of interest

The authors declare no conflict of interest.

References

Obarisiagbon

, Azodo

, Omoaregba

, James

. Clinical anxiety among final year dental students: The trainers and students perspectives. Sahel Med J. 2013;16(2):64.

Ezegbe

, Eseadi

, Ede

, Igbo

, Anyanwu

, Ede

, et al. Impacts of cognitive-behavioral intervention on anxiety and depression among social science education students: A randomized controlled trial. Medicine. 2019;98(15):e14935.

Strøm

, Skaare

, Willumsen

. Dental anxiety in 18-year-old Norwegians 1996 and 2016. Acta Odontol Scand. 2020;78(1):13–19.

Depression

. Other Common Mental Disorders. Global Health Estimates. 2017.

Watkins

, Hunt

, Eisenberg

. Increased demand for mental health services on college campuses: Perspectives from administrators. Qual Soc Work. 2012;11(3):319–337.

Lipson

, Lattie

, Eisenberg

. Increased rates of mental health service utilization by US college students: 10-year population-level trends 2007–2017. Psychiatr Serv. 2019;70(1):60–63.

Dyrbye

, Thomas

, Shanafelt

. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81(4):354–373.

Al-Sowygh

, Alfadley

, Al-Saif

, Al-Wadei

. Perceived causes of stress among Saudi dental students. King Saud Uni J Dent Sci. 2013;4(1):7–15.

Babar

, Hasan

, Ooi

, Ahmed

, Wong

, Ahmad

, et al. Perceived sources of stress among Malaysian dental students. Int J Med Edu. 2015;6:56–61.

10.

Kumar

, Dagli

, Mathur

, Jain

, Prabu

, Kulkarni

. Perceived sources of stress amongst Indian dental students. Eur J Dent Edu. 2009;13(1):39–45.

11.

Polychronopoulou

, Divaris

. Dental students’ perceived sources ofstress: a multi-country study. J Dent Edu. 2009;73(5):631–639.

12.

Pau

, Rowland

, Naidoo

, AbdulKadir

, Makrynika

, Moraru

, et al. Emotional intelligence and perceived stress in dental undergraduates: a multinational survey. J Dent Edu. 2007;71(2):197–204.

13.

Abu-Ghazaleh

, Rajab

, Sonbol

. Psychological stress amongdental students at the University of Jordan. J Dent Edu. 2011;75(8):1107–1114.

14.

Ahmad

, Md Yusoff

, Razak

. Stress and its relief among undergraduate dental students in Malaysia. Southeast Asian J Trop Med Public Health. 2011;42(4):996–1004.

15.

Alzahem

, Van der Molen

, Alaujan

, Schmidt

, Zamakhshary

. Stress amongst dental students: a systematic review. Eur J Dent Edu. 2011;15(1):8–18.

16.

Tangade

, Mathur

, Gupta

, Chaudhary

. Assessment of stress level among dental school students: an Indian outlook. Dent Res J. 2011;8(2):95–101.

17.

Sugiura

, Shinada

, Kawaguchi

. Psychological well-being andperceptions of stress amongst Japanese dental students. Eur J DentEdu. 2005;9(1):17–25.

18.

Basudan

, Binanzan

, Alhassan

. Depression, anxiety and stress in dental students. Int J Med Edu.. 2017;8:179–186.

19.

Brondani

, Ramanula

, Pattanaporn

. Tackling stress management, addiction, and suicide prevention in a predoctoral dental curriculum. J Dent Edu. 2014;78(9):1286–1293.

20.

Rada

, Johnson-Leong

. Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc. 2004;135(6):788–794.

21.

James

, Rimes

. Mindfulness-based cognitive therapy versus pure cognitive behavioural self-help for perfectionism: A pilot randomised study. Mindfulness. 2018;9(3):801–814.

22.

Tooth

, Tonge

, McManus

. Anxiety and study methods in preclinical students: causal relation to examination performance. Med Edu. 1989;23(5):416–421.

23.

Moss

, McManus

. The anxieties of new clinical students. Med Edu. 1992;26(1):17–20.

24.

Obarisiagbon

, Azodo

, Omoaregba

, James

. Do stages of dentistry training affect anxiety provoking situations? Ann Med Health Sci Res. 2014;4(6):869–874.

25.

Hashmi

, Aftab

, Naqvi

, Sajjad

, Mohsin

, Khawaja

. Anxiety and depression in Pakistani medical students: a multicenter study. Health Med. 2014;8(7):813–820.

26.

Shah

SIA

, Ahmed

. Medical students’ anxiety on beginning clinical studies. Al Ameen J Med Sci. 2013;6(3):195–201.

27.

Acharya

. Factors affecting stress among Indian dental students. J Dent Edu. 2003;67(10):1140–1148.

28.

Gazal

, Allazqani

, Fareed

, Alolayan

, Omar

, Nassani

. Clinical anxiety among junior dental students: Trainers and students’ perspective. Saudi J Oral Dent Res. 2016;1(3):108–112.

29.

Almalik

, Alnowaiser

, El Meligy

, Sallam

, Balkheyour

. Clinical anxiety among Saudi postgraduate pediatric dentistry students in Jeddah city. Int J Dent. 2018;2018:5863869. https://doi.org/10.1155/2018/5863869

30.

Halboub

, Alhajj

, Al-Wesabi

, Al-Sanaani

, Mufadhal

. Dentalenvironment and war-related stress among dental students, Yemen. Eastern Mediterr Health J. 2019;25(8):529–536.