Stress is a physical or psychological phenomenon developed through self-cognition of provoking factors, after interacting with one’s surroundings.¹ Stress is experienced by many people in a variety of social, academic, and work settings. Although stress can be a source of motivation, excess stress can be debilitating.²

High levels of stress may have a negative impact on the students' learning ability. Studies have reported a high prevalence of stress among medical students ranging from 25–90%.^3,4 A recently published systematic review reported that dental students also experience significant amounts of stress.⁵ Dentistry has been frequently rated as an exceptionally stressful profession; starting as a student and progressing into clinical practice after graduation.^6-8 Naidu and colleagues reported that stress among first and second  year dental students was mainly academic in comparison to largely clinical and interpersonal relationship-related stress among students during clinical years.⁹ This could be due to the pressures of starting clinical practice, financial problems, social issues with colleagues or patients, and the stress of practice management.¹⁰

Studies have shown that students who were under high stress continuously were emotionally exhausted and had been suffering from mental distress, physical manifestations, and eventually, burnout.¹¹ Therefore studies have been done on dental students in different countries, focusing on stress during their learning and training stage.^2,7,8 Interestingly some of the studies have also linked the perception of stress with gender, academic year and living environment.¹² In 2009, Polychronopoulou et al suggested that dental undergraduates are constantly stressed as they need to be competent in both academic and clinical aspects as much as in interpersonal skills.¹¹ They concluded that these perceived stress factors varied significantly between students from different institutions and were closely linked to gender, level of study, class size, type of curriculum and educational fees.¹¹ Likewise Tangade et al reported fear of failure as the top stressor among the students and observed an increasing trend of stress from first through the final year of study.¹³ Between genders, studies in Europe, Japan and Saudi Arabia have shown that female students had higher stress scores than male students, whereas an Indian study found no difference.^{11, 12-14}

In view of the literature, it is crucial to have a better understanding of students’ perceived stress factors which would in turn contribute to building a positive and effective learning environment.¹¹ Hence, the objective of the present study were  to determine the stress levels and perceived sources and factors affecting stress among Malaysian dental students.

The findings of this study provided an interesting and useful insight into a subject that is often not viewed as a priority. The top stressors perceived by dental students are related to academic issues, which is consistent with previous investigations.^6,13 Fear of failure in a course was ranked as  the most stressful item across all professional years and  appeared similar to what was reported by Tangade and Colleagues.¹³ These findings may help in improving strategize to which may enable students to overcome the academic life related stressors. Similarly, while viewing various aspects of academic stress, it was also found that senior (final year) students expressed greatest stress in all the academic related items, which might be an indication of the pressure to graduate while facing the challenges of professional life. Year three students in the present study had the lowest overall academic stress, which again found in concordance with other reported studies.^13,17 However, in contrast to  previous studies, we found peak in stress level among third year students  which coincides with the transition from pre-clinical to clinical phase.^9,13,19,20 Stressed students may become detached and unable to focus their emotions and intentions, therefore it is worth noting that an earlier Malaysian study had found that third-year dental students had the lowest mean empathy score when compared to students in other study years.²¹

In the context of stress due to personal issues, students from clinical years reported significantly higher anxiety, related to lack of confidence in becoming a successful professional and fear of being unable to catch up if getting behind in the studies. This may be due to their busy schedule combined with their aspiration to be competent both academically and clinically. Another interesting finding was that fear of unemployment upon graduation was perceived most stressful among students in their initial years with a decreasing trend seen as they proceed to the clinical years. Studies in India and Nigeria found the opposite trend and students were more anxious about their future as they progressed.^11,19 Greater job security in Malaysia caused by paid compulsory government service and vacancy in private practice may explain the relatively lower fear of unemployment.

Increasing trends in stress were observed in both educational environment and learning clinical skill domains, where lack of cooperation from lecturers and patients raised concern among students. In addition students worried about inconsistent feedback from their lecturers. Peretz et al have also reported inconsistency in receiving feedback as a major source of stress.²³ One interpretation is that senior students’ reported greater stress in education and clinical skills domains with increased interaction with faculty members and patients as well as high expectation from faculty members as they enter the clinical phase. This interpretation is consistent with findings from Greece and India.^19-20 Our findings that senior years student suffered from greater stress are supported by previous studies suggesting that the coursework becomes more difficult with each passing year.^9,12,24 Noteworthy differences were observed when items were analyzed across gender. Female students reported higher levels of stress than their male counterpart in all aspects, which is in agreement with previous studies.^6,14,25,26 However, Sofola et al reported that stress levels were not different between genders while Archarya et al reported that male students perceived greater overall stress.^20,21 Higher stress reported by females may be due to the way they respond to stressful events and males being less expressive of their worries.^26,12 From our results, it can be projected that almost one quarter (24.2%) of the students opted for the dental programme due to parental pressure. Parents who micromanage their kids in every decision “helicopter parents” may also lead to academic stress and this may have long term detrimental effects on their academic and professional life. 

Finally, students from public institutions appeared more stressed than their private university counterparts. This may be due to differences in English language requirements and assessment (type and frequency) of private versus public universities. Surprisingly, no significant differences related to financial resources were found even though tuition fee at private institutions can be very high. This might due to the availability of educational loans by the government as well as scholarships and education sponsored funds by private companies. Furthermore, students who registered for dental courses in private universities in Malaysia may be able to afford the education costs and thus express lesser financial pressure. As expected, fear of unemployment upon graduation was the only stressor where students from private universities scored higher, perhaps due to the worries of getting high income jobs to repay on their investment.

The students reported higher levels of stress. The most frequently occurring stressors among the students were are related to academic issues. Academic and non-academic stressors should be considered in curriculum planning and a mechanism should be in place to monitor and address dental students’ stress. Stressed students may benefit by improving academic support systems via senior students, academic staff and counselor driven continuous mentoring. To accomplish this requires increased stress awareness, improved coping skills and focused support. In some cases involvement of the parents may be necessary. The experience of personal and professional stress does not end at graduation, students must be equipped with the necessary skills to assess personal distress, determine its effect on professional growth, recognize when to seek help, and develop strategies to promote personal well-being.