Recognising the signs and understanding the implications chronic stress can cause to mental and physical health

As dental professionals, we understand how stress affects general oral health in many ways. We see from our patients how it can lead to poor oral hygiene habits, poor nutrition, an increase in smoking and alcohol, cold sores, aphthous ulcers, xerostomia, and the toothwear and jaw pain that comes from bruxing. Research demonstrates that stress is a modifiable systematic risk factor for periodontal diseases, including periodontitis, necrotising periodontal diseases, and peri-implant diseases (British Society of Periodontology, 2016).

Globally, stress is at a historic high (Gallup, 2023). In the UK last year, a poll found that 91% of adults experienced high or extreme levels of pressure or stress, leading to 1 in 5 people taking time off of work (Mental Health UK, 2024).

Dentists and DCPs are in a particularly demanding profession. In a 2019 survey of UK dentists, 54.9% reported high stress levels in their jobs, with general dental practices being the highest reported stressful dental setting (Colin et al. 2019). Furthermore, research published by the DDU found that 68% of dental professionals reported their stress levels to be higher since the pandemic (Design, 2020).

This article will cover a brief history of stress, good versus bad stress and how to tell the difference, chronic stress in dental professionals, the potential warning signs and effects, and what to do if you think you may be experiencing chronic stress.

Stress is a state of mental tension that promps us to address challenges or threats in our lives (World Health Organisation, 2023). It is a natural human feeling and can be our body's reaction to help us deal with a difficult situation or demand. In the short-term, this ''acute stress'' response can be advantageous. However, too much stress, or ''chronic stress'', can negatively impact our health both mentally and physically.

This natural human response has been known throughout history by many names, from a case of ''the vapours'' in the 1700's, to ''hysteria'' or ''nerves'' in the 1800's (Briner, 2001). If we look even further back to prehistoric times, we can understand how stress is a consequence of our biological evolution.

When our ancestors came upon enemies or wild animals, their adrenal glands were stimulated to sercrete adrenaline and noradrenaline, activating their sypathetic nervous system. This caused increased heart and breathing rates, pupil dilation, and glucose release into the bloodstream for increased energy (Eysenck, 2009). Historically, these primitive physiological mechanisms were triggered to ready us either for combat or flight. Then when we were out of danger, our bodies could recalibrate and switch back into the energy-saving parasympathetic nervous system. Our psychological defences come down and our true emotions emerge (Nerurkar, 2024), letting us process and move on from the initial stress response.

Stress is a fundamental part of our human survival. In the short term, stress can serve a role and be healthy. It can be a positive drive that allows us to improve our focus, run on time, and manage medical emergancies. this ''good stress'' or ''eustress'' is temporary and helps us learn new skills and experience the rewarding satisfaction that comes with being a dental care professional.

Our bodies are skillfully equipped to manage this rapid short-term “fight or flight” state, but when we function in this mode for long periods of time, resources are used up. This triggers a delayed response in the hypothalamic–pituitary–adrenocortical axis (HPA), which induces long-lasting effects in the body via the endocrine system, particularly through increased secretion of the hormone cortisol (Eysenck, 2009). This protective mechanism helps us cope with long-term stress, but over time its continuous activation can be harmful to many of the body’s systems. This is what is known as “bad” or “chronic stress”.

In our modern world, stressors are not acute like wild animals and enemies, they are chronic, such as health issues, life changes, bills, relationship difficulties, financial troubles, and work pressures.

A rapid evidence assessment from the GDC in 2021 found that factors influencing stress for the dental team related to business, time pressures, clinical work, regulators, the effects of the pandemic, the fear of litigation, patient complaints, and factors outside of the working environment (Plessas et al., 2021). Similarly, a survey of stress, burnout and well-being in UK dentists reported the top 10 sources of stress to be the threat of complaints/litigation, dissatisfied patients, the risk of masking a mistake, red tape/bureaucracy, concerns about the GDC, NHS targets, running behind schedule, NHS work, working quickly to see as many patients as possible, and difficult patients (Collin et al., 2019).

From my own personal experience as a dental hygienist & therapist, I have found that devoting my attention span to seeing multiple patients back-to-back, continuously carrying out meticulous near work, making on-the-spot clinical decisions, and repeatedly empathising with patients’ pain and discomfort is mentally and emotionally exhausting. When our brains don’t get the chance to rest and recharge, chronic stress sets in.

The chronic stress response can damage cells and organs across many systems of the human body such as the cardiovascular, endocrine, musculoskeletal, nervous, respiratory, and reproductive systems (APA, 2023). As such, research and literature on the damage of the stress response spans across many scientific disciplines from psychology and medicine to physiology and immunology. Some effects are summarised below:

• The constant supply of our emergency hormones increases the likelihood of depression, anxiety disorders, stress disorders, and burnout
• Consistent ongoing increased heart rate and blood pressure can cause hypertension and atherosclerosis, further increasing the chances of a heart attack or stroke
• Cortisol tells us to replenish our body’s fuel through high sugar and high fat “comfort food”, increasing visceral fat – the harmful type of fat found around our organs which makes us more likely to develop heart disease or insulin resistance
• The stress response is communicated to the intestinal nervous system and can cause bloating, diarrhoea, nausea, constipation, vomiting, changes in appetite, acid reflux and heartburn
• Chronic muscle tension as a result of stress has been associated with migraines, tension headaches, and pain in the neck and upper back
• The immune system is suppressed, meaning infections are more likely to develop, and wound healing is impaired
• Stress has also been linked to the development of asthma and rheumatoid arthritis
• Problems in the reproductive system may arise from decreased libido and irregular periods, to reduced fertility and even diseases of the reproductive organs
• Weight changes, hair loss, irritability, acne and fatigue have also been found to be related to chronic stress

(APA, 2023), (Eysenck, 2009), (Nerurkar, 2024), (Sproule, C. 2018). 

Like computer malware running in the background of our brains, chronic stress can remain undetected as it wreaks havoc and makes changes in our systems. We need to be on the lookout for our body’s physical and emotional warning signs, alerting us that we are stuck in this state. Signs and symptoms of chronic stress include headaches, muscle tension, neck or back pain, chest pain or jitters, rapid heartbeat, dry mouth, changes in appetite, difficulty falling or staying asleep, fatigue, increased frequency of illness, lack of focus, forgetfulness, irritability and anxiety (APA, 2020).

The best thing you can do is know your symptoms. Be aware of changes in your mood such as negative thoughts about yourself or others, and changes in your lifestyle such as doing less of the activities you usually enjoy or isolating yourself. Pay attention to the signs and listen to your body.

Stress is a part of life, especially when working in the high-pressure dental environment. What matters most is how you respond to the stress. If you are particularly concerned, you should seek professional help by first contacting your GP. Otherwise, there are some key things you can do to manage stress and anxiety:

• Try to identify the cause of your stress: Could you cut down your work hours? Or learn a new skill to improve your confidence and relieve your anxieties? Are you due some time off for a rest away from work?
• Take care of yourself: Make lifestyle changes that support your physical and emotional health, such as a balanced diet, regular exercise, and developing good sleeping habits and bedtime routines
• Learn to enjoy mindful relaxation: Stretching in between patients, deep breathing during treatment, massages and yoga to ease your aches and improve your posture
• Connect with others: Foster healthy working relationships with nurses and receptionists, talk with friends and family, try to talk openly about your feelings and get worries off your chest
• Keep a reflection or gratitude journal: Practicing reflection can help you to identify particular stressors and develop strategies to manage them
• Practice self-compassion: Accept what you can't control and stop worrying about situations you can't change. Try to replace negative thoughts with more balanced or rational and positive thoughts

APA (2020). Listening to the warning signs of stress. Available at: https://www.apa.org/news/press/releases/warning-signs.pdf.

APA (2023). Stress Effects on the Body. [online] American Psychological Association. Available at: https://www.apa.org/topics/stress/body.

Briner, Rob. (2001). The Stress Myth: S Doublet. Chesterfield, MO: Science & Humanities Press, 2000, pp.287, US$24.95. ISBN: 1-888-725-36-2. International Journal of Epidemiology - INT J EPIDEMIOL. 30. 10.1093/ije/30.6.1500-a.

British Society of Periodontology (2016) The good practitioner's guide to periodontology. British Society of Periodontology. http://www.bsperio.org.uk

Collin, V., Toon, M., O'Selmo, E. et al. A survey of stress, burnout and well-being in UK dentists. Br Dent J 226, 40–49 (2019). https://doi.org/10.1038/sj.bdj.2019.6

Design, D. (2020). DDU survey finds majority of dental professionals believe stress and anxiety levels have increased. [online] The Probe. Available at: https://the-probe.co.uk/blog/2020/07/ddu-survey-finds-majority-of-dental-professionals-believe-stress-and-anxiety-levels-have-increased/

Eysenck, M. W. (2009). Fundamentals of Psychology. Hove, England: Psychology Press.

Gallup (2023). State of the Global Workplace 2023 Report: The Voice of the World’s Employees. Washington, DC. https://www.gallup.com/workplace/349484/state-of-the-global-workplace.aspx

Mental Health UK (2024). The Burnout Report - January 2024. [online] mentalhealth-uk.org/burnout. Available at: https://euc7zxtct58.exactdn.com/wp-content/uploads/2024/01/19145241/Mental-Health-UK_The-Burnout-Report-2024.pdf [Accessed 22 Jul. 2024].

Nerurkar, A (2024). The 5 Resets: Rewire Your Brain and Body for Less Stress and More Resilience. HarperCollins UK.

Plessas, A., Paisi, M., Bryce, M., Burns, L., O' Brien, T., Witton, R. and Hanoch, Y. (2021). Mental Health and Wellbeing in Dentistry: A Rapid Evidence Assessment. Commissioned by the General Dental Council. [online] Available at: https://www.gdc-uk.org/docs/default-source/research/mental-health-and-wellbeing-in-dentistry27973e06-eb0f-4ee2-b92f-7fee3d2baf5b.pdf.

Sproule, C. (2018). Is Stress affecting your Hormones? [online] The Allergy Clinic. Available at: https://www.bromsgroveallergy.co.uk/uncategorised/stress-affecting-hormones/ [Accessed 22 Jul. 2024].

World Health Organization (2023). Stress. [online] www.who.int. Available at: https://www.who.int/news-room/questions-and-answers/item/stress.