Original Article

Aggravating factor for course requirement

stressor among dental students
Fahad Saleh Al Sweleh, Mohammed Khalid Aldhili1, Yahia Abdullah Alyami2, Mutlaq Khalid Alotaibi3
Department of Dental Clinics, College of Dentistry, King Saud University, Riyadh, 1Department of Dental Clinics, New Najran General
Hospital, 2Department of Dental Clinics, Najran Specialist Dental Center, Najran, 3Department of Dental Clinics, Primary Health Care
Center, Unaizah, Kingdom of Saudi Arabia

Address for correspondence:

Dr. Fahad Saleh Al Sweleh, Objective: To determine the main factor that can aggravate course requirement
ABSTRACT
Department of Dental Clinics, College stressor among dental students at College of Dentistry, King Saud University.
of Dentistry, King Saud University, Materials and Methods: A cross‑sectional study was conducted in College of Dentistry in
P.O. BOX: 35825, Riyadh 11498, King Saud University, Riyadh, Saudi Arabia. This study included all undergraduate students,
Kingdom of Saudi Arabia. who finished their training in the clinics in 2012–2013. The data were collected using a
E‑mail: fsweleh@yahoo.co.uk paper‑based questionnaire that utilized a 5‑Likert scale. Results: The overall response was
80.4% (283/352). Students perceived that stress scale was more than moderate (6.5–7.6).
Third‑year students in operative dentistry course reported the aggravating factor (s) of
course requirement stressor are “number of clinical requirements” and “availability of suitable
patients” (57.5%) and in periodontics is “availability of suitable patients” (50.5%). Fourth‑year
students in removable prosthodontics reported the aggravating factor(s) is “availability of
suitable patients” (56.3%), in fixed prosthodontics are “availability of well‑equipped dental
clinics” and “fluency of laboratory work” (52.4%), in operative dentistry is “number of clinical
requirements” (61.3%), in periodontics are “number of clinical requirements” and “availability
of well‑equipped dental clinics” (48.5%), and in endodontics is “availability of well‑equipped
dental clinics”  (53.3%). Fifth‑year students in removable prosthodontics reported the
aggravating factor(s) is fluency of laboratory work  (60.9%), in fixed prosthodontics are
“availability of well‑equipped dental clinics” (60%) and “fluency of laboratory work” (60%), and
in comprehensive dental clinic are “availability of suitable patients” and “fluency of laboratory
work” (62.7%). Conclusions: Students reported that common aggravating factors for course
requirement stressor are “number of clinical requirements,” “availability of suitable patients,”
“availability of well‑equipped dental clinics,” and “fluency of laboratory work.”

Key words: Clinical requirements, course requirement, dental students, stress, suitable
patients

INTRODUCTION syndrome which consists of all the nonspecifically induced

Stress is a common problem in the daily life of people
experienced during work, study, and social activities. Stress
was defined and described by many authors with different
explanations.
Selye is considered the father of stress research. In 1936, he
defined stress as “the nonspecific response of the body to
any demand made on it;” then, later, in 1976, he modified
the definition of stress to be “a state manifested by a specific
changes within the biological system.”[1,2]
Cox (1978) defined stress as “a stimulus, a response, or the
result of an interaction between the two, with the interaction
described in terms of some imbalance between the person
and the environment.”[3] Baum[4] also defined stress “as a
negative emotional experience accompanied by predictable
biochemical, physiological, and behavioral changes that
are directed toward adaptation either by manipulating the
situation to alter the stressor or by accommodating its effects.”

Access this article online This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
Quick Response Code
others to remix, tweak, and build upon the work non‑commercially, as long as the
Website:
author is credited and the new creations are licensed under the identical terms.
www.saudijhealthsci.org
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Al Sweleh FS, Aldhili MK, Alyami YA, Alotaibi MK.
10.4103/sjhs.sjhs_79_16 Aggravating factor for course requirement stressor among dental students.
Saudi J Health Sci 2017;6:96-103.

96 © 2017 Saudi Journal for Health Sciences | Published by Wolters Kluwer - Medknow
 Al Sweleh, et al.: Aggravating course requirement stressor
The previous different definitions revealed that the stress
affects both the body and the mind of human. However,
some stress is desirable and can cause positive effect on the
individual while chronic and undesirable stress can cause
negative effect on the individual.
Many physiological, psychological, and behavioral signs and
symptoms were mentioned in the literature related to stress.
Physiological effects include fatigue, tension, dizziness,
sweating, tachycardia, gastrointestinal symptoms, weight
loss, and physical complaints. Psychological effects include
anxiety, burnout insomnia, depressive symptoms, emotional
exhaustion, worry, lack of confidence, unhappiness, and
apathy. Behavioral effects include crying, sleeplessness,
cynicism, nervousness, hostility, alcohol consumption, and
cigarette smoking.[5‑12]
Approximately, 600 articles were published that discussed
and investigated medical school stress alone.[13] Alzahem
et al.[6] in their systemic review for dental stress reported that
there were many indicators of stress such as low grades and
marks, low academic achievement, unprofessional attitudes,
illicit drug use, cigarettes smoking, lack of social integration,
depersonalization, depressed mood, and memory problem.
Many students have experienced some form of stress during
their studying. Therefore, signs and symptoms of stress such
as anxiety and depressive symptoms can be seen among
students.[7] However, there was variation in the literature
regarding perceiving stress among gender; female students
perceived more stress generally than male students.[7,14‑23]
Several sources of stress among dental students were
identified by studies conducted in different countries. For
example, lack of leisure time, procrastination, meeting
faculty expectations for workload, and feeling powerless in
the system were reported as major concerns in a national
survey of Canadian dental students,[24] while examinations
and grades were found to be the most potent stressors in an
Australian and Jordanian study.[14,25] In Europe, limited leisure
time, examination anxiety, and adapting to the clinical phase
of dental education were identified as sources of stress in a
study conducted in three European dental schools.[26]
Moreover, the assigned workload, students’ self‑efficacy
beliefs, limited time for working, patient tardiness or no show
for appointments, academic overload, completing clinical
requirements, and criticism by supervisor and excessive work
are considered sources of stress on students.[6,16,27]
Al‑Saleh et  al. investigated the possible stressors faced by
dental students in the Kingdom of Saudi Arabia.[28] The
authors reported that lack of time for relaxation, amount
of study load, and patient being late or not showing were
perceived as the major problems among the surveyed dental
students.[28] The sources and levels of stress and effective
Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017 97
coping strategies for dental students were evaluated by
Al‑Sowygh.[29] The author concluded that the surveyed dental
students displayed relatively high perceived stress scores.
Moreover, the perceived stress of female students, married
students, and those at a higher level of the study were found
to be more as compared to male students, single students,
and those at a lower level of study, respectively.[29]
Dental students perceived that they experienced more
stress than medical students.[30] Therefore, this problem
may negatively affect the academic performance of dental
students.[6]
After searching on websites, PubMed, Google Scholar, Yahoo,
Elsevier, SAGE Online, Education Resources Information
Center, British Medical Journal, Journal of Dentistry, European
Journal of Dental Education, and Journal of Dental Education,
no studies specifically determine the main factor that can
aggravate course requirement stressor in dental education
were found. Therefore, there seems to be a distinct lack
of information regarding perspectives of dental student
regarding clinical course requirement. The aim of this study
is to determine the main factor that can aggravate course
requirement stressor among dental students at the College
of Dentistry of King Saud University.
MATERIALS AND METHODS
A cross‑sectional study design was used in this study to
determine factors of aggravating stress of dental students.
This study was conducted in College of Dentistry, King
Saud University (KSU), in Riyadh, Saudi Arabia, which is the
oldest dental college in the Kingdom established in 1957 as
public college, graduates approximately 100 students/year,
and accommodates approximately 595 students in all levels
(300 male and 185 female students). Dental students must
complete all clinical course requirements to pass the course.
This study included all undergraduate students, who finished
their training in the clinics in 2012–2013 (e.g. 3rd‑, 4th‑,
and 5th‑year students). The 1st‑ and 2nd‑year students were
excluded from the study because they did not start training
in the dental clinics.
Research approval (No. IR0046) was obtained from College
of Dentistry, Research Center of King Saud University, before
the data were collected.
A pilot test was conducted by distributing the questionnaire
to 15 students who finished the previous academic year and
were therefore excluded from the study.
This study used a design to collect numerical data at a point
in time at the end of the clinical training. The data were
collected using a paper‑based questionnaire that utilized a
5‑Likert scale from 1 (strongly disagree) to 5 (strongly agree).
 Al Sweleh, et al.: Aggravating course requirement stressor
Researchers distributed the questionnaire to the dental
students face‑to‑face in the classroom. An introductory
first page was attached to the questionnaire explaining the
purpose of the study and assuring the confidentiality of the
participants’ information.
The questionnaire had stress scale from 0 (not at all stressful)
to 10 (extremely stressful) and nine factors after an initial
demographic section. This questionnaire was validated by
three experts: two are faculties from the College of Dentistry
and one is a psychologist from the College of Education, KSU.
In the questionnaire, students were asked to mark which
among the list of nine factors can aggravate clinical course
requirement stressor. The factors included number of clinical
requirements, number of clinical sessions available to finish
requirement, availability of suitable patients, number of
instructors in the clinical sessions, number of students in
the course, number of assistants in the clinics, availability
of well‑equipped dental clinics, fluency of laboratory work,
and lack of enough time for relaxation between two sessions.
Data were entered into and analyzed using the SPSS software
version 20 (IBM, New York, USA). Subgroups were studied
based on gender and level of student. Frequency tables were
presented for all items. A t‑test was used to determine if
there is any significant difference in the mean of stress scale
between two groups (gender and levels). Proportional t‑test
was used to determine if there is a significant difference in
agreement response between the two groups (gender and
level). A P < 0.05 was considered statistically significant for
all statistical tests.
RESULTS
The overall response rate for completion of the survey
was 80.4% (283/352). Response rate for male students was
66.4% (188/283) and for female students was 33.6% (95/283).
The demographic characteristics of the study population are
given in Table 1.
The mean and standard deviation stress scale according to
gender are given in Table 2. Generally, students perceived
that stress scale was more than moderate which is 6.5–7.6
for all courses, except the periodontics course which had a
low mean stress scale of 4.7. The t‑test showed statistically
significant difference between mean stress scale of male
students as compared to that of female students in the
Table 1: Demographic characteristics of the study population
Level of study Male, n (%) Female, n (%) Total, n (%)
3rd year 69 (70) 30 (30) 99 (77.3)
4th year 74 (72) 29 (28) 103 (74.0)
5th year 74 (67) 36 (33) 110 (88.7)
Total 188 (66.4) 95 (33.6) 283 (80.4)
98 Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017
3rd‑year periodontics course (male 6.51 and female 4.70,
P = 0.005).
Table 3 shows the percentage of aggravating factors of
course requirement stressor for the 3 rd‑year students
according to courses and gender. The majority of 3rd‑year
male students (54.3%) in the operative dentistry course
reported that the “availability of well‑equipped dental clinics”
is the main aggravating factor for course requirement while
the female students (77.4%) reported that the “availability
of suitable patients” is the main aggravating factor. The
aggravating factors of requirement stressor in operative
dentistry course for all 3 rd‑year students are “number
of clinical requirements” and “availability of suitable
patients” (57.5%) as shown in Table 4.
In the periodontics course, the majority of male students
(45.7%) reported that the “number of clinical sessions
available to finish requirement” is the main aggravating factor
while the female students (71%) reported that the “availability
of suitable patients” is the main aggravating factor. The
aggravating factor of requirement stressor in periodontics
course for all 3rd‑year students is “availability of suitable
patients” (50.5%) as shown in Table 4.
Table 5 shows the percentage of aggravating factors of
course requirement stressor for 4th‑year students according
to courses and gender. The majority of 4 th‑year male
students (72.3%) in removable prosthodontics course reported
that the “availability of suitable patients” and “availability of
well‑equipped dental clinics” are the main aggravating factors
for course requirement stressor while female students (80%)
reported that the “availability of suitable patients” is the main
aggravating factor. The aggravating factor of requirement
stressor in removable prosthodontics course for all 4th‑year
students is “availability of suitable patients” (56.3%) as shown
in Table 4.
In the fixed prosthodontics course, the majority of male
students (70.2%) reported that the “availability of suitable
patients” is the main aggravating factor while female
students (76.7%) reported “availability of well‑equipped
dental clinics.” The aggravating factors of requirement
stressor in fixed prosthodontics course for all 4th‑year
students are “availability of well‑equipped dental clinics”
and “fluency of laboratory work” (52.4%) as shown in Table 4.
The majority of male (80.9%) and female (83.3%) students, as
well as all the 4th‑year students (61.2%) in operative dentistry
course, reported that the “number of clinical requirements”
is the main aggravating factor as shown in Table 4.
In the periodontics course, the majority of male students (66%)
reported that the “number of clinical requirements” is the
main aggravating factor while female students (73.3%)
reported that the “availability of suitable patients” is the main
 Al Sweleh, et al.: Aggravating course requirement stressor

Table 2: The mean and standard deviation stress scale according to gender
Level of student Course Gender P
Male Female
Male (n) Mean±SD Female (n) Mean±SD
3rd year Operative dentistry 63 7.24±1.54 16 7.06±2.74 0.808
Periodontics 47 6.51±1.72 10 4.70±2.00 0.005*
4th year Removable prosthodontics 34 6.53±2.13 ‑ ‑ ‑
Fixed prosthodontics 38 7.87±2.02 ‑ ‑ ‑
Operative dentistry 44 6.61±2.26 ‑ ‑ ‑
Endodontics 39 6.54±2.48 ‑ ‑ ‑
Periodontics 36 7.64±1.96 ‑ ‑ ‑
5th year Removable prosthodontics 67 6.48±1.67 23 6.78±2.00 0.475
Fixed prosthodontics 68 6.88±1.51 28 7.07±2.00 0.514
Comprehensive dental clinic 65 7.60±1.71 22 7.41±2.06 0.669
*Statistically significant. SD: Standard deviation

Table 3: Percentage of aggravating factors of course requirement stressor among 3rd‑year students
Aggravating factors Courses
Operative dentistry Periodontics
Male, n (%) Female, n (%) Male, n (%) Female, n (%)
Number of clinical requirements 34 (48.6) 23 (74.2) 27 (38.6) 15 (48.4)
Number of clinical sessions available to finish requirement 33 (47.1) 22 (71) 32 (45.7) 14 (45.2)
Availability of suitable patients 35 (50) 22 (77.4) 28 (40) 22 (71)
Number of instructors in the clinical sessions 32 (45.7) 22 (71) 24 (34.3) 15 (48.4)
Number of students in the course 32 (45.7) 18 (58.1) 26 (37.1) 13 (41.9)
Number of assistants in the clinics 34 (48.6) 20 (64.5) 29 (41.4) 13 (41.9)
Availability of well‑equipped dental clinics 32 (54.3) 20 (64.5) 27 (38.6) 13 (41.9)
Fluency of laboratory work 32 (45.7) 18 (58.1) 24 (34.3) 7 (22.6)
Lack of enough time for relaxation between two sessions 29 (41.4) 23 (74.2) 31 (44.3) 12 (38.7)

aggravating factor. The aggravating factors of requirement
stressor in periodontics course for all 4th‑year students
are “number of clinical requirements” and “availability of
well‑equipped dental clinics” (48.5%) as shown in Table 4.
Furthermore, in the endodontic course, the majority of
male students (72.3%) reported that the “availability of
well‑equipped dental clinics” is the main aggravating
factor for course requirement stressor while female
students (76.7%) reported that the “availability of
well‑equipped dental clinics” and (76.6%) “availability of
suitable patients” are the main aggravating factors. The
aggravating factors of requirement stressor in endodontics
course for all 4 th ‑year students are “availability of
well‑equipped dental clinics” (53.3%).
Table 6 shows the percentage of aggravating factors of course
requirement stressor for 5th‑year students according to
courses and gender. The majority of male students (54.7%) in
removable prosthodontics course reported that the “number
of assistants in the clinics” and “availability of well‑equipped
dental clinics” are the main aggravating factors for course
requirement stressor while female students (73%) reported
that the “fluency of laboratory work” is the main aggravating
factor. The aggravating factor of requirement stressor in
removable prosthodontics course for all 5th‑year students is
fluency of laboratory work (60.9%) as shown in Table 4.
In the fixed prosthodontics course, the majority of male
students (62.7%) reported that the “number of clinical
requirements” is the main aggravating factor while
female students (64.9%) reported that the “number of
clinical sessions available to finish requirement” and
“number of instructors in the clinical sessions” are the
main aggravating factors. The aggravating factors of
requirement stressor in fixed prosthodontics course for all
5th‑year students are “availability of well‑equipped dental
clinics” (60%) and “fluency of laboratory work” (60%) as
shown in Table 4.
In the comprehensive dental clinic course, the majority of
male students (58.7%) reported that the “number of clinical
requirements” and “availability of suitable patients” are the
main aggravating factors for course requirement while female
students (70.3%) reported that the “number of instructors
in the clinical sessions” and “fluency of laboratory work”
are the main aggravating factors. The aggravating factors of
requirement stressor in comprehensive dental clinic course
for all 5th‑year students are “availability of suitable patients”
and “fluency of laboratory work” (62.7%).

Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017 99

 Al Sweleh, et al.: Aggravating course requirement stressor

Table 4: Comparing percentage of aggravating factors of course requirement stressor between 3rd‑, 4th‑, and 5th‑year students
Aggravating Operative dentistry Periodontics Removable Fixed prosthodontics
factors prosthodontics
3rd year, 4th year, P 3rd year, 4th year, P 4th year, 5th year, P 4th year, 5th year, P
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Number of clinical 57 (57.5) 63 (61.3) 0.603 42 (42.4) 50 (48.5) 0.382 45 (43.6) 59 (53.6) 0.145 44 (42.7) 70 (36.6) 0.002*
requirements
Number of 55 (55.5) 52 (50.5) 0.470 46 (46.4) 44 (42.7) 0.592 50 (48.5) 49 (44.5) 0.559 46 (44.6) 62 (56.3) 0.086
clinical sessions
available to finish
requirement
Availability of 59 (57.5) 55 (53.4) 0.373 50 (50.5) 48 (46.6) 0.579 58 (56.3) 59 (53.6) 0.695 53 (51.4) 64 (58.2) 0.323
suitable patients
Number of 54 (54.5) 50 (48.5) 0.393 39 (39.3) 35 (33.9) 0.424 47 (45.6) 62 (56.3) 0.115 45 (43.6) 61 (55.4) 0.084
instructors in the
clinical sessions
Number of 50 (50.5) 36 (34.9) 0.024* 39 (39.3) 41 (39.8) 0.952 48 (46.6) 50 (45.4) 0.867 42 (40.7) 49 (44.5) 0.578
students in the
course
Number of 54 (54.5) 49 (48.5) 0.320 42 (42.4) 40 (38.8) 0.603 48 (46.6) 62 (56.3) 0.152 50 (48.5) 56 (50.9) 0.730
assistants in the
clinics
Availability of 52 (52.5) 53 (51.5) 0.879 40 (40.4) 50 (48.5) 0.243 54 (52.4) 63 (57.2) 0.477 54 (52.4) 66 (60) 0.264
well‑equipped
dental clinics
Fluency of 50 (50.5) 44 (42.7) 0.266 31 (31.3) 28 (27.2) 0.519 53 (51.4) 67 (60.9) 0.163 54 (52.4) 66 (60) 0.264
laboratory work
Lack of enough 52 (52.5) 46 (44.7) 0.262 43 (43.4) 37 (35.9) 0.274 42 (40.7) 38 (34.5) 0.348 38 (36.8) 48 (43.6) 0.315
time for relaxation
between two
sessions
*Statistically significant

Table 4 shows that there were statistically significant
differences between 3rd‑year and 4th‑year students who
reported “number of students in the course” as the main
aggravating factor of course requirement stressor in the
operative dentistry course (3rd year is 50.5% and 4th year
is 34.9%, P = 0.024). Furthermore, there were statistically
significant differences between 4th‑year and 5th‑year students
who reported that the “number of clinical requirements”
in Fixed Prosthodontics course (4th year is 42.7% and 5th is
36.6%, P = 0.002).
DISCUSSION
students as compared to female students in periodontics
course. This partially corroborates with the results of a previous
Indian study[23] which reported that males suffered greater
stress than females.
The 3rd‑year students perceived that “availability of suitable
patients” in operative and periodontology course is an
aggravating factor; this finding may be due to early clinical
exposure to the students and limited suitable patient to their
level. Moreover, students in this level are not familiar with new
situations and responsibility. Other study refers this stress
to the effect of transition from preclinical to clinical level.[29]

Many studies found that dental students perceive stress due to
difficulty to complete clinical requirements.[6,29‑31] The current
study aimed to determine the main factor that can aggravate
course requirement stressor among dental students at the
College of Dentistry in KSU in Riyadh, Saudi Arabia according to
their level and gender. The result of the current study revealed
that the level of stress scale among the surveyed Saudi dental
students was more than the middle. The perception of stress
scale was influenced by the level and gender. Some studies
have reported the existence of gender differences in stress
perception among dental students,[14,20] whereas some other
studies did not find any such differences.[8,17] The mean stress
scale in the present study was higher among 3rd‑year male
Students in 3rd and 4th year perceived that the number
of clinical requirements in operative and periodontology
courses is the main aggravating factor. This finding is in
agreement with the study of Al‑Sowygh which found that
“clinical requirements” was the greatest stressor for 4th‑ and
5th‑year students.[29] Perceiving this factor may be due to large
number of clinical procedures that student should finish to
pass the course. Other studies found that completing clinical
requirements and workload in clinical years were substantial
stressors. [25,28] Increase number of clinical requirement
is type of more workload on students. The Greek dental
students reported that one of the sources of stress in dental
college is assigned workload.[27] Dodge et al.[32] studied the

100 Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017
 Al Sweleh, et al.: Aggravating course requirement stressor

Table 5: Percentage of aggravating factors of course requirement stressor among 4th‑year students in removable and fixed
prosthodontics, operative dentistry, periodontics, endodontics courses
Aggravating factors Courses
Removable Fixed Operative Periodontics Endodontics
prosthodontics prosthodontics dentistry
Male, Female, Male, Female, Male, Female, Male, Female, Male, Female,
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Number of clinical 31 (66) 14 (46.7) 28 (59.6) 16 (53.3) 38 (80.9) 25 (83.3) 31 (66) 19 (63.3) 32 (68.1) 17 (56.7)
requirements
Number of clinical 32 (68.1) 18 (60) 27 (57.4) 19 (63.3) 30 (63.8) 22 (73.3) 26 (55.3) 18 (60) 31 (66) 20 (66.7)
sessions available to finish
requirement
Availability of suitable 34 (72.3) 24 (80) 33 (70.2) 20 (66.7) 34 (72.3) 21 (70) 26 (55.3) 22 (73.3) 31 (66) 23 (76.6)
patients
Number of instructors in 26 (55.3) 21 (70) 26 (55.3) 19 (63.3) 29 (61.7) 21 (70) 20 (42.6) 15 (50) 26 (55.3) 18 (60)
the clinical sessions
Number of students in the 33 (70.2) 15 (50) 27 (57.4) 15 (50) 23 (48.9) 13 (43.3) 25 (53.2) 16 (53.3) 28 (59.6) 15 (50)
course
Number of assistants in the 29 (61.7) 19 (63.3) 30 (63.8) 20 (66.7) 29 (61.7) 20 (66.7) 23 (48.9) 17 (56.7) 32 (68.1) 18 (60)
clinics
Availability of 34 (72.3) 20 (66.7) 31 (66) 23 (76.7) 31 (66) 22 (73.3) 30 (63.8) 20 (66.7) 32 (72.3) 23 (76.7)
well‑equipped dental clinics
Fluency of laboratory work 31 (66) 22 (73.3) 32 (68.1) 22 (73.3) 27 (56.4) 17 (56.7) 16 (34) 12 (40) 18 (38.3) 10 (33.3)
Lack of enough time for 27 (57.4) 15 (50) 25 (53.2) 13 (43.3) 27 (57.4) 19 (63.3) 25 (53.2) 12 (40) 24 (51.1) 16 (53.3)
relaxation between two
sessions

Table 6: Percentage of aggravating factors of course requirement stressor among 5th‑year students in (prosthodontics,
comprehensive dental clinic) course
Aggravating factors Courses
Removable Fixed Comprehensive
prosthodontics prosthodontics dental clinic
Male, Female, Male, Female, Male, Female,
n (%) n (%) n (%) n (%) n (%) n (%)
Number of clinical requirements 40 (53.3) 19 (51.4) 47 (62.7) 23 (62.2) 44 (58.7) 18 (48.6)
Number of clinical sessions available to finish requirement 32 (42.7) 17 (45.9) 38 (50.7) 24 (64.9) 32 (42.7) 20 (54.1)
Availability of suitable patients 39 (52) 20 (54.1) 43 (57.3) 21 (56.8) 44 (58.7) 25 (67.6)
Number of instructors in the clinical sessions 40 (53.3) 22 (59.5) 37 (49.3) 24 (64.9) 40 (53.3) 26 (70.3)
Number of students in the course 34 (45.3) 16 (43.2) 34 (45.3) 15 (40.5) 37 (49.3) 22 (59.5)
Number of assistants in the clinics 41 (54.7) 21 (56.8) 39 (52) 17 (45.9) 32 (50.7) 23 (62.2)
Availability of well‑equipped dental clinics 41 (54.7) 22 (59.5) 45 (60) 21 (56.8) 40 (53.3) 22 (59.5)
Fluency of laboratory work 40 (53.3) 27 (73) 43 (57.3) 23 (62.2) 43 (57.3) 26 (70.3)
Lack of enough time for relaxation between two sessions 27 (36) 11 (29.7) 30 (40) 18 (48.6) 36 (40) 15 (40.5)

effect of a clinical program based on patient needs not unit
requirements on academic achievement. They found that
the nonrequirement group had significantly higher academic
achievement and significantly out produced compared to
their classmates (requirement group).
The 3rd‑year students in operative dentistry and periodontology
and 4th year in periodontology, removable prosthodontics,
and endodontic course perceived that the “availability of
suitable patients” was the main aggravating factor which is in
agreement with other studies which found that getting suitable
patients cause more stress to the students.[28,29] Completing
treatment plan of the patient is a must to pass the course
that is why student wants suitable patient match the criteria
of the course level to avoid any delay to the student. Getting
suitable patient aggravates requirement stressor because
criteria of suitable patient such as having simple procedure for
early clinical course and having high level of compliance are
not easy for student. For example, if patients being late or not
showing for their appointment, this will cause more stress for
student as mentioned by other studies.[22,25,28] Similar findings
were reported with dental student in Jordan,[25] Singapore,[33]
United Kingdom,[16] and Australia.[14]
The 4th‑year (in fixed prosthodontic) and 5th‑year students (in
fixed prosthodontics, removable prosthodontics, and

Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017 101
 Al Sweleh, et al.: Aggravating course requirement stressor
comprehensive dental clinic) perceived that the “fluency of
laboratory work” was main aggravating factor. These findings
attributed to number of cases and clinical requirements of
prosthodontics courses which need multiple laboratory
procedures and cooperation from laboratory technician. One
study found that stress levels increase during the 5th year of
the program due to more work during this year.[20]
Generally, perceiving aggravating factor increases from 3rd‑ to
4th‑year students in similar courses such as operative dentistry
and periodontology. This finding was attributed to increase
the number of clinical requirements in the 4th year compared
to the 3rd year.
Commonly reported aggravating factors in 3rd‑, 4th‑, and
5th‑year students were “number of clinical requirements,”
“availability of suitable patients,” and “fluency of laboratory
work.” These findings were not in accordance with the
results of an Indian study conducted by Kumar et al.,[34] which
evaluated the perceived sources of stress among dental
undergraduate students at a private dental institution. The
results showed that the two highest stressors among 3rd‑ and
4th‑year male students were “examination and grades” and
“atmosphere created by clinical supervisors.”[34]
Dental students need counseling and help from psychologist
provided by the college to overcome any stress source or
effect.[6] Furthermore, students need stress management
program during their study to prevent and manage the stress
early to support students effectively and academically by
explaining the expected outcome of stress.[6]
Some limitations of this study need to be considered when
interpreting the results. The 4th‑year female students did
not answer the stress scale question which resulted in lack
of data, limit interpretation of the findings for comparison
of stress scale of female students at different levels.
Another limitation was that it was done in one College of
Dentistry that reflects local condition of students which limit
generalizability of the findings. Furthermore, this study was
conducted in one academic year only which did not reflect
how the students perceive over long time to determine the
aggravating factor of stressor for many years.
Further, more study is needed to evaluate the effect
of modified clinical requirement on students’ stress.
A prospective longitudinal study might be encouraged to
follow and monitor dental student stressors change through
students’ academic progress.
CONCLUSIONS
Students perceived that stress scale is more than moderate
in many courses. The present study showed that common
aggravating factors for course requirement stressor are as
follows:
102 Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017
• “Number of clinical requirements” with 3rd‑ and 4th‑year
students (in operative dentistry) and with 4 th‑year
students (in periodontology)
• “Availability of suitable patients” with 3rd‑year students (in
operative dentistry and periodontology) and with 4th‑year
students (in removable prosthodontics)
• “Availability of well‑equipped dental clinics” with 4th‑year
students (in periodontics and fixed prosthodontics) and
with 5th‑year students (in fixed prosthodontics)
• “Fluency of laboratory work” with 4th‑year students
(in fixed prosthodontics) and with 5th‑year students (in
removable prosthodontics and fixed prosthodontics).
Modifying course requirement is necessary for learning not
for performing. Competency‑based learning is the trend of
education in the world. Implementing stress management
programs in the college is important to reduce the
complication of stress.
Acknowledgments
We wish to thank the College of Dentistry Research Center
at the King Saud University and Mr. Nassr Al‑Maflehi for his
guidance in statistical analysis. We also wish to thank the
students for their participation in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. The American Institute of Stress. What is Stress?; 2014. Available from:
http://www.stress.org/what‑is‑stress/. [Last cited on 2014 Feb 01].
2. Selye H. Wikipedia; 2014. Available from: http://www.en.wikipedia.org/
wiki/Hans_Selye. [Last cited on 2014 Feb 01].
3. Mackay  C, Cox  T, Burrows  G, Lazzerini  T. An inventory for the
measurement of self‑reported stress and arousal. Br J Soc Clin Psychol
1978;17:283‑4.
4. Baum A. Stress, intrusive imagery, and chronic distress. Health Psychol
1990;9:653‑75.
5. Wexler M. Mental health and dental education. J Dent Educ
1978;42:74‑7.
6. Alzahem  AM, van der Molen  HT, Alaujan  AH, Schmidt  HG,
Zamakhshary MH. Stress amongst dental students: A systematic review.
Eur J Dent Educ 2011;15:8‑18.
7. Peterlini M, Tibério IF, Saadeh A, Pereira JC, Martins MA. Anxiety and
depression in the first year of medical residency training. Med Educ
2002;36:66‑72.
8. Muirhead V, Locker D. Canadian dental students’ perceptions of stress
and social support. Eur J Dent Educ 2008;12:144‑8.
9. Cecchini JJ, Friedman N. First‑year dental students: Relationship
between stress and performance. Int J Psychosom 1987;34:17‑9.
10. Grandy TG, Westerman GH, Lupo JV, Combs CG. Stress symptoms among
third‑year dental students. J Dent Educ 1988;52:245‑9.
11. Knudsen W. Quality of life of the dental student. Tandlakartidningen
1978;70:183‑6.
12. Tedesco LA. A psychosocial perspective on the dental educational
experience and student performance. J Dent Educ 1986;50:601‑5.
 Al Sweleh, et al.: Aggravating course requirement stressor
13. Shapiro SL, Shapiro DE, Schwartz GE. Stress management in medical
education: A review of the literature. Acad Med 2000;75:748‑59.
14. Sanders AE, Lushington K. Sources of stress for Australian dental
students. J Dent Educ 1999;63:688‑97.
15. Morse Z, Dravo U. Stress levels of dental students at the Fiji School of
medicine. Eur J Dent Educ 2007;11:99‑103.
16. Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental
students. Dent Update 1999;26:94‑8, 100.
17. Sofola OO, Jeboda SO. Perceived sources of stress in Nigerian dental
students. Eur J Dent Educ 2006;10:20‑3.
18. Sugiura G, Shinada K, Kawaguchi Y. Psychological well‑being and
perceptions of stress amongst Japanese dental students. Eur J Dent
Educ 2005;9:17‑25.
19. Rosli TI, Abdul Rahman R, Abdul Rahman SR, Ramli R. A survey of
perceived stress among undergraduate dental students in Universiti
Kebangsaan Malaysia. Singapore Dent J 2005;27:17‑22.
20. Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and
psychological disturbance among dental students in the West Indies.
J Dent Educ 2002;66:1021‑30.
21. Westerman GH, Grandy TG, Ocanto RA, Erskine CG. Perceived sources
of stress in the dental school environment. J Dent Educ 1993;57:225‑31.
22. Pau AK, Croucher R. Emotional intelligence and perceived stress in
dental undergraduates. J Dent Educ 2003;67:1023‑8.
23. Acharya S. Factors affecting stress among Indian dental students. J Dent
Educ 2003;67:1140‑8.
24. Bradley IF, Clark DC, Eisner JE, De Gruchy K, Singer DL, Hinkleman K,
Saudi Journal for Health Sciences - Volume 6, Issue 2, May-August 2017 103
et al. The student survey of problems in the academic environment in
Canadian dental faculties. J Dent Educ 1989;53:126‑31.
25. Rajab LD. Perceived sources of stress among dental students at the
University of Jordan. J Dent Educ 2001;65:232‑41.
26. Pöhlmann K, Jonas I, Ruf S, Harzer W. Stress, burnout and health in the
clinical period of dental education. Eur J Dent Educ 2005;9:78‑84.
27. Polychronopoulou A, Divaris K. Perceived sources of stress among
Greek dental students. J Dent Educ 2005;69:687‑92.
28. Al‑Saleh SA, Al‑Madi EM, Al‑Angari NS, Al‑Shehri HA, Shukri MM. Survey
of perceived stress‑inducing problems among dental students, Saudi
Arabia. Saudi Dent J 2010;22:83‑8.
29. Al‑Sowygh ZH. Academic distress, perceived stress and coping strategies
among dental students in Saudi Arabia. Saudi Dent J 2013;25:97‑105.
30. Murphy RJ, Gray SA, Sterling G, Reeves K, DuCette J. A comparative
study of professional student stress. J Dent Educ 2009;73:328‑37.
31. Muirhead V, Locker D. Canadian dental students’ perceptions of stress.
J Can Dent Assoc 2007;73:323.
32. Dodge WW, Dale RA, Hendricson WD. A preliminary study of the effect
of eliminating requirements on clinical performance. J Dent Educ
1993;57:667‑72.
33. Yap AU, Bhole S, Teo CS. A cross‑cultural comparison of perceived
sources of stress in the dental school environment. J Dent Educ
1996;60:459‑64.
34. Kumar S, Dagli RJ, Mathur A, Jain M, Prabu D, Kulkarni S. Perceived
sources of stress amongst Indian dental students. Eur J Dent Educ
2009;13:39‑45.
Copyright of Saudi Journal for Health Sciences is the property of Medknow Publications &
Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.