A survey of dental students’ perceptions of stress indicates that
academic factors and faculty relationships with students are
the areas that create the most stress. Differences between
the four classes in the ranking of several areas reflect the
differences in academic and clinical requirements and
Perceived sources of stress among
dental students
W illiam H. Garbee, Jr., DDS, MEd
Steven B. Zucker, DDS, MEd
Gary R. Selby, DDS
T T h e professional educational process can be a
stressful experience. Much has been written about
the presence of this psychological stress (defined as
feelings of discomfort, tension, or distress) in m edi­
cal schools.1'5 A cadem ic pressures associated with
the overwhelming amount of difficult material that
has to be mastered and the com prehensive exam ina­
tions that require m uch study time to pass leave lit­
tle time for students to release the accum ulated ten­
sion and anxieties. Emotional stress produced by the
discrepancy between student expectations and the
reality of medical school further intensify the psy­
chological stress.
Dental school is also a highly pressurized, dif­
ficult environment for students.6-9 Because of a strict
curriculum that occupies m ost of the students’ day­
tim e h o u rs, d en tal s c h o o l is a fu ll-tim e job.
Academ ic and clinical requirements extend stu­
dents’ working hours into the nights and weekends.
As a result, students have little time for relaxation or
for their friends, spouse, or family.6 The demands of
dental school are frequently unlike anything that
students have experienced in their undergraduate
training. Heavy emphasis in clinical sciences re­
quires students to concentrate heavily on manual
skills rather than on the traditional academ ic skills.
The stresses of dental school may have undesir­
able consequences. The Council on Dental Educa­
tion in 1977 reported that students who withdrew
from dental school for personal reasons were usu­
ally not in academ ic difficulty but withdrew for
experience associated with each class.
other reasons.10 This group represents a half of the
1976 total attrition rate of 7%. Approxim ately as
many students are dropping out of first-year dental
school for personal reasons as those that are w ith­
drawing for academ ic reasons.10 Horton11 reported
that the majority of students who were given a leave
of absence ranked in the upper half of their class in
their predental academ ic record, and their rank
while in dental school was spread uniformly across
the class. A lthough predental grades and DAT
scores might reflect accurately the nonsuccess of
students dismissed from school for academ ic rea­
sons, it cannot be considered a predictor of success
for students who drop out or take a leave of absence.
A second undesirable consequence of stress is
psychological and physical distress. K nudson,6
W exler,7 and M artin ez,12 suggest th at students
under stress may show symptoms of distress such as
anxiety, depression, hostility, fear, and tension.
Symptoms may range from mild apprehension to a
sense of overwhelming panic— from inability to
start an activity or, once begun, to sustain it— to se­
vere feelings of guilt and worthlessness. Physical
symptoms may also be present. Among the more
common are gastrointestinal symptoms, bowel dis­
turbances such as diarrhea or constipation, loss of
appetite or gluttony, sleeplessness, intense fatigue,
dizziness, tachycardia, feelings of a lump in the
throat, dry mouth, and excessive palm sw eating.7
The most important undesirable effect of stress as
far as dental education is concerned is the impair-
JADA, Vol. 100, June 1980 ■ 853
ment of effective intellectual function and detriment
to learning. Severe stress-producing depression and
anxiety with or without physical symptoms can
immobilize students, making them ineffective in
dealing with the demands of a difficult academ ic
curriculum .7 Many students find themselves in a
continuous conflict between the necessity to study
and the necessity to relax or do something uncon­
nected with dentistry.6 Faced with this paradox,
students may show m uch frustration, which is often
aimed at the faculty and administration who are
blamed for causing the problems.
W hy some students display symptoms of their
distress and others do not can be attributed to indi­
vidual differences in tolerance to and m otivation by
stress.13'15 Stress is a part of every individual’s life
and is the motivation of many achievem ents; with­
out adequate stimulation, most individuals would
suffer as m uch as from overstimulation. Thus, stress
is a two-edged sword which can either motivate the
student to peak performance or reduce the student to
ineffectiveness. The problem m ay not be the events
themselves but rather “the results of our own inap­
propriate patterns of psychological and emotional
responses.” 13
The approach to the question of stress in dental
school in the current study is to identify perceived
sources of stress which require a more in-depth in­
vestigation and to consider briefly some possible
outcom es of perceived stress.
M ethod
A questionnaire was distributed to the student body
through individual mailboxes. The questionnaire
(Illustration) contained 25 items designed to iden­
tify potential areas of stress in the dental school edu­
cation; students were asked to label items as stress­
ful or as highly stressful on 5-point Likert scales.
The survey instrument was field-tested for reliabil­
ity and revised to one page to minimize time and
confusion. The estimated time to complete the ques­
tionnaire was approxim ately ten minutes.
Results
An overall response rate of 35% (N = 152) was ob­
tained. Distribution by classes was 36% (n = 3 9 )
freshmen, 44% (n = 4 7 ) sophomores, 28% (n = 40)
juniors, 24% (n = 2 6 ) seniors. Because of the small
number of women respondents, the results were not
reported separately for men and women. Every ques­
tion did not elicit a total response of 152 as every
question was not applicable to all students. Stress
scores were obtained for each item by assigning a
value of 10 to 50 for each item with 10 indicating
stressful and 50 indicating very stressful. A mean
stress score was calculated with use of the average
854 ■ JADA, Vol. 100, June 1980
Stress factors in the dental educational environment
1. Stress due to amount of classwork
2. Stress due to difficulty of classwork
3. Stress due to examinations and grades
4. Stress due to peer competition
5. Stress due to patient care responsibilities
6. Stress due to difficulty in learning clinical procedures
7. Stress due to patients’ attitudes toward me
8. Stress due to patients’ attitudes toward dentistry
9. Stress due to atmosphere created by clinical professors
10. Stress due to difficulty in learning precision manual skills re­
quired in preclinicai and laboratory practice
11. Stress due to reliability of professional dental laboratories in
prompt return of cases
12. Stress due to administrative responses to student needs
13. Stress due to roommate relationships
14. Stress due to dating relationships
15. Stress due to alcohol usage
16. Stress due to drug usage
17. Stress due to reconsideration of dentistry as proper career
choice
18. Stress due to fear o f flunking out of school
19. Stress due to marriage relationship
20. Stress due to child care
21. Stress due to financial responsibilities
22. Stress due to personal physical health
23. Stress due to physical health of other family members
24. Stress due to parent-student relationship
25. Stress due to other personal problems
Students were asked to rate level of stress factors in range from least
stressful to very stressful.
stress score given each item by all four dental classes
which served as the basis for ranking the items
(Table 1).
The three areas perceived as the most stressful
were related to the academ ic environment of dental
education and the clinical environment created by
the faculty. Rated as the most stressful item was
“atmosphere created by clinical professors” which
received the highest stress rating possible from 42%
of the respondents. The academ ic items, ranking
second and third respectively,.were “ examinations
and grades” and “ amount of classw ork.” These
items received the highest stress rating possible
from 33% and 20% of the respondents, respectively.
The three highest ranked items recorded a mean
stress score of 39.0 for the clinical professor item,
Table 1 ■ Sources of stress for dental students.
Mean
stress
Source of stress score*
1. Atmosphere created by clinical professors 39.0
2. Examinations and grades 37.5
3. Amount of classwork 36.0
4. Patient care responsibilities 28.9
5. Administrative response to student needs 28.2
6. Difficulty of classwork 28.0
7. D ifficulty in learning precision manual skills 27.8
8. Peer competition 26.7
9. Difficulty in learning clin ical procedures 26.6
10. Financial responsibilities 24.8
•Mean = 2 2 .4 ; N = 152.
37.5 for exam inations, and 3 6 .0 for classwork. Other
areas ranked m oderately stressful include “ patient
care responsibilities,” mean stress score of 28.9;
“administrative response to student needs,” mean
stress score of 2 8 .2 ; and “ difficulty of classw ork,”
mean stress score of 28.0.
The stress items w ere also grouped into seven
composite categories of related items. The mean
stress score for each category was calculated by tak­
ing the average score of each item in the category.
Ranking of the com posite catégories (Table 2) indi­
cates that the category “faculty and adm inistration”
had the highest average mean stress score of 33.6.
“A cad em ic” was the second highest ranking cate­
gory with a mean stress score of 32.0. Categories
recording moderate m ean stress scores were “m an­
ual skills,” “financial obligations,” and “patient
care.”
Rankings of the stress items by the four classes
were consistent am ong the top three items with only
slight variations in the order. Am ong the other
items, a greater variation in the rankings was ob­
served, although only one item was ranked in the
top ten by one class and not the others. “Reliability
of professional dental laboratories in prom pt return
of cases” was ranked fourth by the senior class. “Pa­
tient care responsibilities” was ranked highest by
the junior class and “ difficulty of classw ork” was
ranked tenth by the juniors. Table 3 shows the class
differences in the rankings of the ten highest ranked
stress items.
Discussion
The results of this study indicate that students are
concerned with their relationships to the faculty and
administration as w ell as their ability to grasp and
absorb the am ount of material presented to them.
This is reflected in their ratings of the items referring
to these areas and the com posite ratings of stress
categories of faculty and administration, academ ics,
and manual skills. These com posite categories were
rated considerably higher than areas related to pa­
tient care, personal problems, family, and even fi­
nancial obligations.
The im portance of good student-faculty relation­
ships, as evidenced by student rankings of this item
as the m ost important stress area, parallels findings
by Goldstein9 and H ollinshead16. Hollinshead re­
ported that among the problems m entioned by stu­
dents in his study were poor student-faculty rela­
tionships, excessive pressures, and the fears gener­
ated by these conditions. Similarly, Goldstein found
that inconsistent feedback from faculty members
was one of the prim ary stresses in the first year of
dental school.
The im portance of instructors in the growth of
professional attitudes in dental students is well-
Table 2 ■ Ranking of stress composite categories.
Average
mean
stress
Source of stress score*
1. Faculty and administration 33.6
2. Academics 32.0
3. Manual skills 27.2
4. Financial obligations 24.8
5. Patient care . 23.2
6. Personal problems 16.4
7. Family__________________ 15.2
*M ean = 2 2 .4 ; N = 152.
known. However, there exist in nearly every school
some instructors who behave in a professionally un­
acceptable m anner.17 A certain am ount of tension
exists between students and faculty as a result of the
faculty’s evaluative and authoritative role. Some of
the stress that students perceive as being caused by
thè faculty is attributable to this role and is unavoid­
able. However, the high rating of faculty-student re­
lationships as a stressor indicates that some faculty
members may abuse their evaluative prerogative
and their authority.
In addition to student-faculty relations, one of the
chief findings in the current study is the importance
of students’ fears concerning their own inadequacy
or incom petence. Students ranked high items relat­
ing to examinations, am ount of classwork, and diffi­
culty pf classwork. In this respect, the findings par­
allel findings of similar studies in both m edical and
dental schools.15,9 Considering the large quantities
of difficult material that students are required to
master, it is not surprising that students often con­
sider themselves inadequate for the task.
The low composite ratings given family and per­
sonal problems indicate that these areas are not con­
sidered as stressful as the academ ic and clinical as­
pects of dental education. Although some students
reported as highly stressful their marriage relation­
ships, personal problems, and problems with al­
cohol or drugs, these students were a small percent­
age of the total population. Several “high-stress”
students rated stress in their marriage high; they
also indicated a high degree of stress from alcohol,
drugs, and personal problems; these students also
tended to have degrees of stress in academ ic and
clinical areas. These students probably had an espe­
cially high level of stress and were operating near
their lim it of stress endurance. A fter a student
re a c h e s th e lim its of s tre s s to le r a n c e , m o re
symptoms of stress should be observable. This area
of study needs further investigation.
A surprising result of the study w as the small
number of survey items w ith a m ean stress score
greater than 30.0, the value assigned for a “m oder­
ately stressful” rating. Only the top three items in
Table 1 received a rating greater than 3 0 .0 ; the re­
maining seven items received ratings ranging from
Garbee-Zucker-Selby : STRESS AMONG DENTAL STUDENTS ■ 855
24.0 to 2 8 .9 , indicating that students considered
them less than “m oderately stressful.” In addition,
the mean stress score for the entire questionnaire of
22.4 was also low er than the 30.0 score. It appears
that students perceive the dental school environ­
ment as generally less stressful than expected; how­
ever, certain areas are highly stressful to a large
number of students and are a cause for concern by
the dental school faculty.
Differences between the classes in ranking items
should be exp ected as each class had different
academ ic and clinical requirements. The amount of
academ ic work was m ost intensive in the first two
years w hereas the clin ical responsibilities were
heaviest during the junior and senior years. The
ranking of “patient care responsibilities” third by
juniors indicated that they found beginning an un­
familiar area of their training stressful for them; pre­
viously, they had had only limited responsibilities
for patient care. Class rankings of “ difficulty in
learning clinical procedures” also reflected this dif­
ference between the classes in emphasis of their cur­
riculum . As the sophomores were just beginning to
learn clinical procedures, they were distressed the
most by this item, whereas juniors and seniors who
had had more experience ranked the item lower.
Freshm en had not had enough experience to be too
concerned about learning clinical procedures. “ Fi­
nancial responsibilities” were more stressful for
freshmen faced with the prospects of having to pay
for three more years than seniors who were ready to
enter the professional world and collect fees for their
services. Seniors w ould naturally be m ore con­
cerned about the dental laboratory being prom pt in
delivery of their cases, as they were trying to meet
deadlines for com pletion of graduation require­
ments. There is some indication that the total per­
ceived stress is slightly higher in the junior and
senior classes, as dem onstrated by the increased
mean stress score for each class and the greater
number of survey items w ith stress scores greater
than 30.0 or a “m oderately stressful” score (Table 3).
Summary
W ith the limited purpose of this study, the findings
presented raise a number of questions about dental
education w hich require further study. Students are
concerned about how they are treated by the faculty.
Faculty are frequently hard on them when trying to
motivate them to better performance. Possibly, bet­
ter w ays of motivating students could be used—
methods that would not create such high degrees of
stress. Students need to be treated as professionals.
Ways to accom plish this need to be investigated.
Students are concerned about the academ ic pres­
sures of dental school. W hereas rigorous training in
dental school is necessary to prepare students, are
the demands made by different departments realis­
tic and in the students’ interest, or is there com peti­
tion between departments for the students’ tim e? If
stress is to be used as a determinant of students’ abil­
ities to withstand the day-to-day stress of practicing
dentistry, should not optimal regions of stress be de­
fined so that predictions can be made of how well
students will perform under stress?
Students react in different ways to stress in vary­
ing intensity. Those who have a background that
predisposes them to feel greater stress require more
assistance in handling this stress. The types of sup­
ports or services that are required need to be iden­
tified and provided for student assistance.
Conclusions
The area identified as m ost stressful by all the
classes together was the student-faculty relation­
ship.

Table 3 ■ Class differences in perception of sources of stress.

Ranking by class*

Source of stress Freshman Sophomore Junior Senior

1. Atmosphere created by
clinical professors 2(36.5) 2(39.3) 1(42.1) 2(38.1)
2. Examinations and grades 1(37.7) 1(39.4) 4(34.5) 1(38.5)
3. Amount of classwork 3(31.3) 3(38.5) 2(36.8) 3(37.3)
4. Patient care responsibilities 8(23.5) 6(27.9) 3(35.1) 8(29.2)
5. Administrative response to
student needs 9(23.4) 9(26.2) 5(32.4) 5(30.8)
6. Difficulty of classwork 4(27.2) 4 9 5(30.8)
7. Difficulty in learning precision
manual skills required in
preclinical and laboratory work 5(25.9) 8(27.1) 6(29.7) 9(28.5)
8. Peer competition 7(24.9) 6(27.9) 10(23.2) 5(30.8)
9. Difficulty in learning
clinical procedures 10(22.8) 5(29.6) 7(28.1) 10(25.9)
10. Financial responsibilities 6(25.4) 10(24.5) 8(27.6) 12(21.6)
Reliability of professional
dental laboratories in
prompt return of casest 4(32.3)
*M ean for all classes = 22.4; freshman, x = 21.3; sophomore, x = 2 1 .5 ; junior, x = 2 3 .3 ; senior, x = 23.8; N = 152.
tRanked in top ten by one class and not others.

856 ■ JADA, Vol. 100, June 1980

 A cadem ic factors such as am ount and difficulty of
classw ork w ere also considered very stressful.
Students found m astery of the m anual skills
needed for laboratory and clinical work somewhat
stressful.
There was a high consistency among the classes in
the rankings of the top, three stress items.
Variations in ranking of items by the classes re­
flected differences that existed in the academ ic and
clinical requirements of each class.
Certain high-stress students reported stress in
academ ic as well as personal areas and appeared to
need special assistance.
The authors would like to thank Mrs. Cathy Daigle and Mrs. Flora Sorina
for help in preparation of the manuscript.
Dr. Garbee is an assistant professor, department of community and pre­
ventive dentistry, Louisiana State University, School of Dentistry, 1100
Florida Ave, New Orleans, 70119, Dr. Zucker was and Dr. Selby is an assis­
tant professor, department of community dentistry, Medical College of
Virginia Commonwealth University, Richmond. Dr. Zucker is currently
assistant director, Area Health Education Center program, Eastern Virginia
Medical School, Norfolk. Address requests for reprints to Dr. Garbee.
1. Boyle, B.P., and Coombs, R.H. Personality profiles related to emo­
tional stress in the initial year of medical training. J Med Educ 46(2):882-
887,1971.
2. Cobum, D., and Jovaisas, A.V. Perceived sources of stress among
first-year medical students. J Med Educ 50:589-595,1975.
3. Adsett, C.A. Psychological health of medical students in relation to
medical education process. J Med Educ 43:728-734,1968.
4. Rosenberg, P. P. Students’ perceptions and concerns during their first
year in medical school. J Med Educ 46:211-218,1971.
5. Gottheil, E„ and others. Stress, satisfaction, and performance: transi­
tion from university to medical college. J Med Educ 44:270-277,1969.
6. Knudsen, W. (ed.). The quality of life of the dental students. Intern
Dent J 28(3):327-331,1978.
7. Wexler, M. Mental health and dental education. J Dent Educ
42(2):74-77, 1978.
8. Lorencki, S.F. The need for a counseling service in a dental school. J
Calif Dent Assoc 41(6):520-521,1965.
9. Goldstein, M.B. Sources of stress and interpersonal support among
first-year dental students. J Dent Educ 43(12):625-629,1979.
10. Council on Dental Education. Dental student attrition. JADA
97(5):817-829,1977.
11. Horton, P.S. Can academic distress be predicted prior to dental
school? J Am Coll Dent 45(2):111-119,1978.
12. Martinez, N.P. Assessment of negative effects in dental students. J
Dent Educ 41(1):31,1977.
13. Gross, N.E. Living with stress. New York, London:McGraw-Hill,
1958.
14. Selye, H. Stress with distress. Philadelphia, J. B. Lippincott Co.,
1974.
15. Selye, H. Stress of life. New York, McGraw-Hill, 1956.
16. Hollinshead, B.S. Survey of dentistry. Washington, American
Council on Education, 1962, pp 338-345.
17. Moore, D.M. The dental student: attitudes associated with the dental
school. J Am Coll Dent, 29:140-164,1962.
Garbee-Zucker-Selby : STRESS AMONG DENTAL STUDENTS ■ 857