Dental Environment Stress: Findings among Lusophone Dental Students

Joao Paulo Menck Sangiorgio, Patricia Medeiros Araujo, Camila Hirata Navarro, Igor Renan Zen, Silvano Cesar da Costa, Patricia Helena Vivan Ribeiro, Antonio Ferelle, Cássia Cilene Dezan-Garbelini



Objective: To perform cross-cultural adaptation of the Dental Environment Stress (DES), to test its construct validity and reliability, and to identify the sources of stress among Brazilian dental students. Material and Methods: The DES was transculturally adapted to Portuguese using translation/back-translation, review by an expert bilingual committee and consensus building. The first version was tested in a sample of 42 dental students to check the understanding level of the alternatives. The final version was applied to all the students enrolled in a Brazilian Public Dental School. Construct validity was assessed through factor analysis, performed by principal components analysis and Varimax rotation and reliability by internal Cronbach’s alpha coefficient (95% CI). Wilcoxon rank sum was conducted to test for gender and Kruskall-Wallis for year comparison. Multivariate analysis relied on ordinal logistic regression modeling. Results: Factor analysis revealed five factors that possessed eigenvalues greater than 1.5 and together explained 46.88% of the total variance. Internal consistency of each factor was adequate, with Cronbach's alpha ranging from 0.65 to 0.84.  ‘Examinations and grades’ (82.80%) was the highest scored item. Females presented higher rates, as well as second’s and fifth’s years students. The entering students were generally concerned with factors related to “Academic Performance”, whereas clinical year students with “Insecurity Concerning their Professional Future”. Conclusion: The Portuguese version of the DES presented good results, thus it could be a valid instrument to assess the factors of perceived stress in Lusophone countries, subsidizing the development of strategies to minimize the stress and optimize school performance.



Dental Stress Analysis; Translating; Surveys and Questionnaires.

Full Text:



Kay EJ, Lowe JC. A survey of stress levels, self-perceived health and health-related behaviours of UK dental practitioners in 2005. Br Dent J 2008; 204(11):E19; discussion 622-3.

Alzahem AM, Van der Molen HT, Alaujan AH, De Boer BJ. Stress management in dental students: a systematic review. Adv Med Educ Pract 2014; 5:167-76.

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(1):8-18.

Iacovides A, Fountoulakis KN, Kaprinis S, Kaprinis G. The relationship between job stress, burnout and clinical depression. J Affect Disord 2003; 75(3):209-21.

Polychronopoulou A, Divaris K. A longitudinal study of Greek dental students’ perceived sources of stress. J Dent Educ 2010; 74(5):524-30.

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(1):39-45.

Humphris G, Blinkhorn A, Freeman R, Gorter R, Hoad-Reddick G, Murtomaa H, et al. Psychological stress in undergraduate dental students: baseline results from seven European dental schools. Eur J Dent Educ 2002; 6(1):22-9.

Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, Bedos C. A systematic review of stress in dental students. J Dent Educ 2014; 78(2):226-42.

Garbee WH, Zucker SB, Selby GR. Perceived sources of stress among dental students. J Am Dent Assoc 1980; 100(6):853-7.

Muirhead V, Locker D. Canadian dental students’ perceptions of stress and social support. Eur J Dent Educ 2008; 12(3):144-8.

Silverstein ST, Kritz-Silverstein D. A longitudinal study of stress in first-year dental students. J Dent Educ 2010; 74(8):836-48.

Pozos Radillo BE, Tórrez López TM, Aguilera Velasco MDLA, Acosta Fernández M, González Perez GJ. Stress-associated factors in Mexican dentists. Braz Oral Res 2008; 22(3):223-8.

Guillemin F. Cross-cultural adaptation and validation of health status measures. Scand J Rheumatol. 1995; 24(2):61-3.

Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: Literature review and proposed guidelines. J Clin Epidemiol 1993; 46(12):1417-32.

Sussman S, Palinkas LA. Reflections on international translation of evidence-based health behavior programs. Eval Health Prof 2008; 31(3):323-30.

Brasil. Ministério da Saúde. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução CNE/CES 1.300/2001 de 06 de novembro de 2001. Diretrizes curriculares nacionais dos cursos de gradução em farmácia e odontologia. Superior CN de EC de E, ed. 2001;1:25.

Conway JM, Huffcutt AI. A review and evaluation of exploratory factor analysis practices in organizational research. Organ Res Methods 2003; 6(2):147-68.

Agresti A. An introduction to categorical data analysis. 2.nd. ed. Hoboken, NJ: Wiley-Interscience; 2007.

Sugiura G, Shinada K, Kawaguchi Y. Psychological well-being and perceptions of stress amongst Japanese dental students. Eur J Dent Educ 2005; 9(1):17-25.

Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25(24):3186-91.

Fonseca J, Divaris K, Villalba S, Pizarro S, Fernandez M, Codjambassis A, et al. Perceived sources of stress amongst Chilean and Argentinean dental students. Eur J Dent Educ 2013; 17(1):30-8.

Morita MC, Haddad AE, Araújo ME. Perfil atual e tendências do cirurgião-dentista Brasileiro. Maringá: Dental Press; 2010.

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(9):1021-30.

Terwee CB, Bot SDM, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007; 60(1):34-42.

Coles C. Medicine and stress. Med Educ 1994; 28(1):3-4.

Rubenstein LK, May TM, Sonn MB, Batts VA. Physical health and stress in entering dental students. J Dent Educ 1989; 53(9):545-7.

Sarid O, Anson O, Bentov Y. Students’ reactions to three typical examinations in health sciences. Adv Heal Sci Educ 2005; 10(4):291-302.

Dodge WW, Dale RA, Hendricson WD. A preliminary study of the effect of eliminating requirements on clinical performance. J Dent Educ 1993; 57(9):667-72.

Wetherell J, Mullins G, Hirsch R. Self-assessment in a problem-based learning curriculum in dentistry. Eur J Dent Educ 1999; 3(3):97-105.

Curtis DA, O’Sullivan P. Does trainee confidence influence acceptance of feedback? Med Educ 2014; 48(10):943-5.

Sanders A, Lushington K. Effect of perceived stress on student performance in dental school. J Dent Educ 2002; 66:75-81.

Eva KW, Armson H, Holmboe E, Lockyer J, Loney E, Mann K, et al. Factors influencing responsiveness to feedback: On the interplay between fear, confidence, and reasoning processes. Adv Heal Sci Educ 2012; 17(1):15-26.

Sanders AE, Lushington K. Sources of stress for Australian dental students. J Dent Educ 1999; 63(9):688.