Exploring stressors in paediatric dentistry clinical training among Polish and International dental students at the Medical University of Lodz

Exploring stressors in paediatric dentistry clinical training among Polish and International dental students at the Medical University of Lodz | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Exploring stressors in paediatric dentistry clinical training among Polish and International dental students at the Medical University of Lodz Agnieszka Bruzda-Zwiech, Julia Durka This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6238639/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Providing dental treatment for children during clinical training appears challenging for undergraduate students. Various factors, including overall perceived stress (PS) and studying overseas, may affect the way students interpret stressful situations. To gain deeper insights into these issues, an anonymous online questionnaire, consisting of a 5-point scale of stress related to paediatric dentistry training, questions regarding its sources, and the Perceived Stress Scale (PSS-14), was sent via e-mail to 4th- and 5th-year students. A total of 115 students (40 out of 50 enrolled in the English-taught dentistry program and 75 out of 248 Polish) completed the survey. Polish students showed a statistically higher mean PSS-14 score compared to their foreign counterparts (34.106 vs. 27.575, p = 0.000). The mean rating of stress linked to clinical training did not differ significantly between Polish and international students (2.95 vs. 3.23), and for both groups, it correlated with PS level. Respondents identified endodontic treatment and local anaesthesia as the most stress-inducing. Polish students ranked the child's attitude as the top stressor, followed by the supervisor’s attitude, whereas international students ranked them inversely. Only 30% of international and 22.6% of Polish students expressed interest in choosing it after graduation. Supervisors should be aware of stressors inherent to clinical training and differences in stress perception between overseas and native students to mitigate the effects of stress and enhance students’ motivation for future paediatric dentistry practice. Biological sciences/Psychology Health sciences/Health care Health sciences/Health occupations Health sciences/Medical research perceived stress paediatric dentistry clinical training dental students Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION As per Lazarus and Folkman's perspective, stress can be defined as a specific interaction between an individual and their surroundings, wherein the person perceives it as placing demands or challenges that exceed their capacity to deal with it and pose a threat to their overall well-being, psychologists also suggested that the way we would interpret an event and emotions that arise from it may have a greater impact on our stress levels than the event itself 1 , 2 . Stress is a pervasive factor among students of all types, particularly manifesting in medical and dental students who contend daily with demanding tasks, vast amounts of study materials, and profound sense of the responsibility associated with patient care 3 . Remarkably, stress levels among dental students have been observed to surpass those among medical students 4 – 6 . This discrepancy may be attributed to factors such as stringent time constraints, the relentless pursuit of aesthetic treatment precision, exacting treatment standards, and intense competitiveness within the field of dentistry. Unfortunately, stress does not go unnoticed; it can persist even after the stressor is removed, affecting students' mental health, eroding their confidence, and significantly influencing their educational performance 7 , 8 . High levels of stress and persistent stress exposure may culminate in burnout syndrome, characterized by the experience of long-term work-related exhaustion and diminished interest low personal accomplishment 9 . 10 . Although burnout refers to a long-term process, it is apparent amongst students too, especially those in their later years of study 10 – 13 . Chronic stress may also encompass a spectrum of health impacts, including physical ailments, such as digestive problems, skin and cardiovascular diseases and psychological manifestations, including hostility and cynicism 11 , 12 . Furthermore, the dental profession, which students will be pursuing after graduation, is considered to be one of the most stressful health professions, among others due to intense interaction between dentist and patient 7 , 9 , 13 . Stress in students may have many sources such as student-related, academic (amount and difficulty of classwork, exams and grades) or faculty-related factors, but senior students additionally face the challenges of clinical training 7 , 10 , 12 , 14 . It is also worth noting extra stressors e.g. the aspects of providing oral care to children or differences in residency status that could impact a particular demographic: students studying overseas. Effective communication is crucial when interacting with patients, as it not only enables the collection of vital information about their health but also helps put them at ease. For students who do not fluently speak the language of the country in which they reside, interacting with native patients can present a challenge. Moreover, the so-called paediatric dentistry treatment triangle, which includes the development of the doctor-patient and doctor-patient’s parent/caregiver relationships, instead of offering a sense of comfort, could potentially add stress for the student providing the treatment to children 15 . In a demanding role such as being an undergraduate dentist, where one must diagnose and treat patients flawlessly while simultaneously preparing for exams, this could potentially emerge as a notable stress-inducing factor, amplifying the overall stress experienced. Though numerous studies have explored the stress experienced by dental students 4 – 10 , 12 , 13 , 14 , 16 – 21 , there has been very limited research focused on stressors related to paediatric dentistry training 22 – 24 . Additionally, due to our best knowledge, no study has compared stress while performing paediatric dental treatments between international and native students in Poland. The Medical University of Lodz offers a 5-year Dentistry program in Polish language, as well as English-taught dentistry program, that has been available for over 20 years. The program of Polish and English divisions of Dentistry at the Faculty of Medicine culminates in the degree of Doctor of Dental Medicine (DMD). Currently, the English division of Dentistry has an international community with students from all over the world. Curriculums of Paediatric Dentistry courses for both Polish and international students are identical, except for the language in which they are taught. The objective of our study was therefore to investigate the level of experienced stress and possible stress-provoking factors related to clinical paediatric dentistry training in undergraduate 4 th− and 5 th− year dental students, and to examine the obtained data in terms of differences between senior students of the English and Polish divisions of Dentistry. Furthermore, the study aimed to assess if overall perceived stress load has an influence on experienced stress when providing dental treatment in children and to investigate the desire of dental students to choose paediatric dentistry specialty as the future career. MATERIALS AND METHODS Study design In this cross-sectional study anonymous questionnaire was sent via e-mail to 4 th− and 5th -year students of the English an Polish divisions of Dentistry during the summer semester of the academic year 2022–2023. The study protocol was approved by the Medical University of Lodz Bioethics Committee, Resolution Number RNN 32/23/KE. The survey was conducted in compliance with the principles of the revised 2013 Helsinki Declaration. The research was carried out in accordance with relevant guidelines and regulations. Data collection The questionnaire was prepared using the Microsoft Forms program and the link was sent to student’s official email accounts addresses in March 2023, thus allowing for the completion within one semester. E-mails with invitation to participate in the survey were sent to all international and Polish senior dental students with a cover letter containing the description of the study purpose, the voluntary, anonymous nature of the study participation, and the link to the questionnaire in English and Polish language, respectively. Upon clicking the provided link, students were directed to the questionnaire. Although, the survey was anonymous, students were asked at the beginning of the questionnaire to confirm that they agreed to participate anonymously in the survey. Informed consent was obtained from all participants. Respondents were not required to provide any personal information, such as their names or surnames, during the questionnaire completion process. This measure was implemented to guarantee the anonymity and confidentiality of the participants. Furthermore, we aimed to prevent students from providing biased responses due to concerns about their answers being visible to any of their teachers. The questionnaire was structured into three segments. The initial section comprised questions aimed at gathering demographic details: study year, age, and gender, if desired. The core part of it contained bespoke questions regarding clinical factors. Students were asked to determine using a 5-point Likert - type scale (ranging from 1 to 5) the following: the level of self-reported stress when performing dental treatments on paediatric patients in general and when performing particular (12 selected) procedures; For analysis, the scores were interpreted: 1- no stress, 2- mild stress, 3- moderate stress, 4-much stress, 5-extreme stress; the influence of the presence of the child's parent during treatment on the level of experienced stress; how the knowledge of the Polish language, allowing for effective communication with patients, affects the treatment time and if it has an impact on achieving treatment success in the dental treatment of children; the impact of preclinical training as well as the number of times they performed the given clinical procedure on their level of confidence in performing paediatric dentistry procedures; the level of agreement (from strongly disagree-1 to strongly agree − 5) to selected statements about the influence of stress on their clinical work quality, and the children’s age as factors exacerbating respondees’ stress during practical paediatric dental training. Furthermore, students were asked to: rank the potential stressors during dental treatment in children including the supervisor's attitude, patient's attitude, time pressure, language barrier, practical skills requirements, theoretical knowledge requirements and strive for perfection in order from the most onerous to the least answer questions: “Do you think paediatric dentistry is an easy specialty? Would you consider working in the field of paediatric dentistry after graduating?” To evaluate the level of overall perceived stress (PS) in students the concluding section of the survey included the Perceived Stress Scale (PSS-14), the internationally recognized self-report psychological assessment tool comprising of seven negative (representing perceived helplessness) and seven positive items (representing self-efficacy) summarized in 14 questions. Respondents were asked how often during the last month they felt or thought a certain way when faced with different situations in their life, and each of the questions required the student to provide a rating on a five-point Likert scale of 0 to 4, with options: “never”, "almost never", "sometimes", "fairly often", and "very often," as appropriate. PSS-14 scores are obtained by reversing the scores on the seven positive items; therefore, they are recoded (0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0), and then summing across all items is done. Total scores range from 0 to 56 and are categorized as Low Stress (scores 0–18), Moderate Stress (scores 19–37), and High Stress (scores 38–56), as coded earlier by Higgins 25 . The Perceived Stress Scale-14 is a commonly utilized tool for gauging the extent to which individuals perceive life situations as laden with stress. The scale originally developed by Cohen et al. (1983), was translated into more than 20 languages 26 . PSS was used for stress perception assessment in research worldwide 27 – 29 , including those on dental students 12 , 14 , 15 . Its psychometric properties in assessing perceived psychological stress have been satisfactorily verified 26 – 29 , and also the Polish version, used in a study of 591 university students, showed good internal consistency and reliability 30 . Statistical analysis Statistical analysis was performed using Statistica for Windows software (version 13.3). The normality of distribution was checked by the Shapiro-Wilk test. The results were expressed as mean ± standard deviation. Comparisons between the study subgroups were performed using the t- test. Correlations were assessed by correlation test (r). Differences were considered significant if p was less than 0.05. Additionally, descriptive analysis for categorical variables was performed (frequency, percentage were calculated). A Chi-squared test was used to analyse the differences in categories of perceived stress between the groups. RESULTS The overall response rate was 38.59% (115 of 298 potential participants). A higher response rate was among international students than Polish one (40 of 50 students − 80% versus 75 of 248–30.24%). The mean age of the respondents was 24 years (ranging from 22–30 years) and was 23.5 vs. 23.66 for native and international students, respectively. Among the participants, 70.43% (n = 81) of the respondents were female and 27.83% (n = 32) were male, and 2 students (1.74%) preferred not to say their gender. Table 1 illustrates the distribution of respondents by year of study and gender. Table 1 The characteristic of the study group. Division of Dentistry Academic year level Male n Female n Prefer not to say n Sum n OVERALL n (%) Polish division 4th year 5 21 - 26 75 (65.22%) 5th year 7 42 - 49 English division 4th year 10 11 1 22 40 (34.78%) 5th year 10 7 1 18 OVERALL n (%) 32 (27.83%) 81 (70.43%) 2 (1.74%) 115 (100%) 115 (100%) Evaluation of student responses, given using a 5-point scale, regarding stress experienced when performing procedures on paediatric patient showed that the mean rating of stress was 3.23 vs 2.95 for the English- and Polish-division students. The stress provoked by providing dental treatment for children did not differ significantly between both groups, and neither were found any differences between male and female students, and when comparing the study years. 98.2% of Polish and 90% of international students reported experienced stress when performing dental procedures in children. Stress level was most often scored 3- moderate stress by international students (40%) and 4 -much stress by native students (34.66%). None of the responders studying at the English division rated stress as extreme, while at the Polish division score 5 was given by 6 students (8%). Figure 1 Table 2 presents mean stress scores for particular dental procedures assessed using a 5-point scale, surveyed according to the study groups. Both Polish students and those studying in English rated stress as being the highest while performing endodontic procedures, however, self-reported mean stress score was significantly higher in Polish students. For both groups of students, the second most stressful procedure was administering local anaesthesia to children. Native students perceive significantly higher stress also during caries cavity preparation in mandibular teeth and while restoring the cavity with composite resin. In contrast, procedures such as topical fluoride application or silver nitrate treatment of early childhood caries and distinguishing between milk and permanent teeth while carrying out dental examination in children with mixed dentition were considered more stressful for students studying English. No statistically significant differences were observed between international and students Polish for other mentioned in Table 2 procedures such as local anaesthesia injection, taking dental impression or simple extraction of milk teeth. Caries removal in mandibular teeth were scored by both groups of students as significantly more stressful than cavity preparation in maxillary teeth (Table 2 ). Table 2 Mean stress scores for particular dental procedures assessed using 5-point scale, surveyed according to the study groups. Procedure Polish division n = 75 English division n = 40, Significance (t, p) mean value ± SD mean value ± SD Distinguishing between permanent and deciduous teeth while caring out dental examination 2.107 ± 1.26 2.7 ± 1.02 t= -2.45957, p = 0.015426 Administration of local anaesthesia 3.6 ± 1.13 3.15 ± 1.27 t = 1.936994, p = 0.0552 Caries removal in maxilla 3.226 ± 1.072 * 2.825 ± 1.21** t = 1.824, p = 0.070767 Caries removal in mandible 2.56 ± 0.989 * 1.8 5 ± 1.098 ** t = 3.525, p = 0.000612 Glass ionomer placement 2.027 ± 1.04 2.05 ± 1.22 t=-0.107902, p = 0.914265 Composite placement 2.507 ± 0.99 2.025 ± 1.16 t = 2.332343, p = 0.021453 Fluoride application 1.133 ± 0.41 1.475 ± 0.98 t=-2.60675, p = 0.010373 Silver nitrate impregnation 1.747 ± 1.0 2.325 ± 1.42 t=-2.53885, p = 0.012482 Indirect pulp capping 3.347 ± 1.12 3.2 ± 1.34 t = 0.622980, p = 0.534553 Endodontic treatment 4.36 ± 0.91 3.675 ± 1.94 t = 3.339, p = 0.001139 Simple deciduous tooth extraction 2.76 ± 1.13 2.45 ± 1.14 t = 1.163, p = 0.247 Taking impressions with alginate 2.707 ± 1.12 2.475 ± 1.13 t = 0.978, p = 0.330 * t = 3,955, p = 0,00018 ; ** t = 3,76, p = 0,00033 Looking for additional factors exacerbating stress, students’ responses to open question (“How much does the presence of a child's parent during treatment affect/increase the level of stress you feel?”) were analysed, and no statistically significant differences were found between Polish students and those studying in English, with mean score of 3.02 vs 2.95. In both groups the most often given scores were 3 and 4. However, in the group of international students, the same percentage of responders reported moderate and much stress (26.66%) while of national students 32.5% reported much stress and 27.5% moderate stress when having the patient guardian in the clinic room while performing dental procedures on the child. Both groups of students agreed with the statement that knowledge of the language the patient communicates in has a significant impact on reducing the length of the visit (mean level of agreement in 5-Likert’s scale was 4.43 for Polish residents and 4.08 for international students, respectively). Similarly, students agreed that the ability to communicate in the patient's language contributes to success of dental treatment in children (mean level of agreement in 5-Likert’s scale was 4.41 for Polish residents and 4.13 for international students, respectively). None of the statistically significant differences were found for the above comparisons. Preclinical training seems to have stronger influence on international students' confidence in performing clinical procedures (mean 3.55 vs 4.28 for Polish and English division students for p = 0.0029 and t = − 3.046). While for Polish students the number of times they perform the given clinical procedure seems more affect their confidence level (mean 4.73 vs 4.3 for Polish and international students for p = 0.01 and t = 2.0461). Analysing students' agreement levels with the statement about the influence of a child’s age as a factor exacerbating stress during practical training showed that the level of experienced stress depends on patient’s age − 42.5% of students enrolled in the English-taught dentistry program and 60% native students agreed or strongly agreed that the younger the patient the more stressed they felt. A higher percentage of Polish than international students agreed or strongly agreed that the level of stress they experience depends on the age of the patient (57.33% vs 32.5%). 60% of native and 52.5% of international responders share the opinion that stress affects the quality of their work. Figure 2 shows students’ agreement rated with 5- point Likert type scale to mentioned statements. Potential stressors ranked by respondents in the online survey, in order from top to bottom stressor are illustrated in Fig. 3 . Patient's attitude was placed at the top of the stressors hierarchy by Polish students, followed by supervisor’s attitude, whereas in international students the hierarchy was reversed, and these factors were ranked second and first place, respectively. However, time pressure was mentioned in third place in both groups of students. Different from Polish students, international students ranked higher the language barrier than theoretical knowledge and practical skills. Most students do not assess paediatric dentistry as an easy speciality (Fig. 4 ) and only 12 of 40 (30%) international students 17 of 75 (22.6%) Polish students showed interest in working in the field of paediatric dentistry after graduating (Fig. 5 ). The mean of the PSS-14 scores was 34.106 ± 7.87 (minimum 19, maximum 46) and 27.575 ± 6.24 (minimum 11 maximum 42) for Polish students and those studying in English, respectively. In both groups the mean score responded to moderate stress level. There were statistically significant differences in perceived stress (PS) between Polish and international students (34.106 vs 27.575 t = 4.68 p = 0.000), also when analysing the score according to genders (34.16 vs. 28.17, t = 3.15, p = 0.002 for comparison between women and 33.83 vs. 26.80, t = 2.60, p = 0.014 for comparison between males, respectively). Figure 6 shows distribution of stress categories (low, moderate and high stress) among the study groups. When comparing the mean score for PSS between females and males within the groups, there were no statistically significant differences for both Polish and international students (34.16 vs 33.83 and 28.16 vs 26.8, respectively). When examining of the PS according to the year of the study we found higher stress in 4th -year Polish students comparing to students enrolled in the English division. Among international students lower stress was observed in 4th -year compared to those of 5th year (34.54 vs 25.59 t = 4.686 and 25.59 vs 30.0 t= -2.347, respectively). No statistically significant differences were shown for comparison of PS between 5th -year students of both study groups (33.88 vs 30.0) and between Polish 4th -and 5th -year students (34.54 vs 33.88) A positive correlation was found between PPS-14 score and level of stress for carrying out dental treatment in children for both Polish and international students (r = 0.3 for p < 0.05 and r = 0.32 for p < 0.05, respectively). DISCUSSION It has been reported previously that dental education is known to be highly demanding and induces considerable stress on students 10 , 16 – 18 . Clinical training seems to be the most critical phase of dental education as students are expected to acquire a wide range of knowledge and skills that should help them succeed in their studies and in providing dental treatment to their patients 20 . Moreover, the clinical years has been shown to be more stressful than the pre-clinical years 7 , 19 . Data from the literature suggest that understanding of how students experience and perceive their studies might be helpful for creating a positive academic environment 20 . In this study, the PSS-14 was employed to measure the general stress load in 4th and 5th -year students and Likert-like scale to pinpoint the specific paediatric dental procedures that exert the most significant stress on students, as that information may be of value not only from psychological point of view, but also might be highly relevant for faculty teachers to guide them on how to support students during clinical courses. In present study, the mean score of overall stress reported by both Polish and international students was within the range of moderate stress level. It is in accordance with results of the surveys on dental students in the UK, North-West Russia and China, in which the shortened version of the PSS with 10 items was used 6 , 10 , 14 . However, we observed higher percentage of both native and international students with high level of stress in (22.5% and 37%, respectively), than it was reported for Russian students (4.9%), but lower comparing to UK dental students (56%) 6 , 10 . What’s more Juszka et. Al, who also used the PSS scale, reported a moderate level of perceived stress among 4th - and 5th -year students. Similarly to our survey, the authors found significantly higher stress levels in Polish students than in international students enrolled in the English division of Dentistry, but only when analysing all students together and specifically for 4th-year students. In contrast to our study, the level of stress among 5 th− year students was higher in international students than in Polish students 18 . In our study, we observed only that the level of stress increased significantly in the final year international students compared to 4th -year ones, while Polish 4 th− year students scored higher than those of 5th year. Also Sanders et al. noted in the group of Australian dental students peaking of the stress at 4th -year of study. 8 Furthermore, in the survey conducted by Gorter et al. 5 th− year students showed relatively high mean MBI (The Maslach Burnout Inventory) scores, and negative development from year one to year five in relation to emotional exhaustion and psychological distress was observed 13 . According to Sanders et al. for senior students, the accumulative effect of stress is also confounded by the increased technical difficulty in performing clinical tasks 8 . This seems to be in line with our observations, as we found a positive correlation between the PPS score and the level of stress experienced when providing dental treatment to children for both native and international students. The increase in perceived daily stress level can be also explained by the findings of other authors that final year students showed greater anxiety about the future 17 . Similarly to the study of Cohen we found no significant difference in PSS scores between male and female students in any of the survey group 26 . Also, other studies conducted in several European dental schools, as well as in China and Mexico didn’t find gender differences in perceived stress assessed using PSS or the Dental Environment Stress (DES) scales 11 , 13 , 14 , 18 , 21 . In addition, Wilson et al. assessed stress among recently graduated dentists and the ones in practice for a longer time and described gender differences only to be significant amongst the latter group 32 . However, data on disparity in perceived stress between genders are not unanimous. Some previous studies that enrolled students of all years noted greater perceived stress scores in female dental students 4 , 6 , 10 , 16 , 18 , 19 . In contrast, research conducted in India showed that male dental students exhibited higher levels of stress than women did which might be associated with sociocultural influences 17 , 33 . However, it has been stated that gender differences in the dental profession would diminish as more females would take on an assertive role in society 13 . The mean PSS-14 score in the sample of senior students enrolled in the English division (25.59) in our study was comparable to the score reported by Singh et al. for last year’s dental students in India (26.86), and slightly higher than that reported by Cohen for the sample of College students in the USA (23.67) 16 , 26 . However, Polish students reported much higher stress level (34.54). The STADA Health Report 2022 online survey of almost 30,000 respondents in 15 European countries showed that Polish adults are most susceptible to feel burnout compared to the rest of Europe. In Poland, 70% of responders reported they have experienced feelings of burnout at least once in their lifetime. The youngest age group surveyed (18-24-year-olds) were shown to be especially susceptible to it 34 . Similar PSS scores to our survey were reported only for senior undergraduate dental students in Saudi Arabia during COVID-19 pandemic (31.33, 33.04 and 34.41 for 4th -, 5th - and 6th - academic year students, respectively) 19 . So, it cannot be excluded that pandemic made students more stressed. Sanders et al. who examined stress level in dental students using DES scale found in category of clinical training no statistical differences in stress score between Australian and international students, however difficulty in learning clinical procedures was ranked higher in stressors’ hierarchy by national than international students. The authors showed higher mean score for international students in comparison to Australian students, when sources of stress such as self-efficacy beliefs, faculty and administration; and peer pressure were analysed. According to the authors this finding may be due cultural determinants (the fact that international students derived mainly from Asian countries) to language difficulties and acculturative adjustment 8 . Even in our study, we focused mainly on the particular dental procedures performed during clinical training as a source of stress, but we tried to determine also the influence of the lingual barrier in effective communication with child patients and supervisors’ attitude. One of the main factors contributing to overall disappointment and the inability to achieve treatment goals with young patients could stem from poor communication, which in case of international students often results from a language barrier between the undergraduate student and the patient. In such scenarios, soothing the child and attaining the desired outcomes can prove to be challenging. Both Polish residents and international students responded that knowledge of the language that patients speak highly affects the treatment success, and additionally, international students ranked the language barrier higher in stressors’ hierarchy than theoretical knowledge and practical skills requirements. The issue of language barrier previously primarily affected international students at our university, given that Polish is considered one of the most challenging languages to acquire. However, due to evolving political dynamics and recent events, it has now become a concern for domestic students as well. Since the beginning of Russian military aggression against Ukraine with the outbreak of a full-scale war in Ukraine and the subsequent massive influx of refugees from that country to Poland, the situation in medical services in Poland changed. The Ukrainian citizens who arrived in Poland on or after February 24, 2022, have the same access to medical care and have been treated like insured Polish citizens by the National Health Fund. As some of these patients and their caregivers may not yet have the proficiency to communicate effectively in Polish, also native dental students have to overcome the problems with the language barrier during providing dental treatment for children as a part of clinical training at medical Universities. A systematic review of stress among dental students showed that of the clinical factors, the major stressor was fear of failure to complete clinical requirements. But, among other factors criticism by supervisors, the atmosphere created by clinical faculty, as well as contact with patients and bearing the responsibility for comprehensive patient care played also important role 7 , 8 . Also, our study confirms those observations as the supervisor’s attitude and patient’s attitude were placed at the top of the stressors hierarchy in both survey groups. Nevertheless, international students ranked higher on the supervisor attitude. It seems to be in line with the results of the above-mentioned study of Sanders et al. that items connected with faculty are stronger stressors for international students, despite the fact that the group evaluated by those authors was made up exclusively of students of Asian origin, and in our study, it was more multicultural 8 . Also, Kaipa et al. showed that 4th -year students in South India perceived the atmosphere created by clinical supervisors (particularly receiving criticism from supervisors) as the highest stress inducing factor, while in studies conducted by Kumar et al. on Indian students and Morse et al. on Fijian students, this factor was ranked third 35 – 37 . This underlines how important role plays academic teacher in creating atmosphere during clinical period of dental education. It should be also noticed that the confidence of new graduates to treat paediatric patients will be influenced by their clinical undergraduate experience 38 . Treating children was reported as the primary reason for the UK community dental service being so stressful 31 . Also, Ayera et al. showed that providing dental treatment to difficult children was the most frequently mentioned stress factor by New Zealand dentists (52%), followed by time pressure mentioned by 48% of responders 39 . This stays in agreement with the results of present study since time pressure was ranked third most stress-inducing factor by both, Polish and international students. Working under time constraints, which is a common occurrence in dentistry, becomes even more pronounced when dealing with children. It is crucial to avoid prolonging treatment sessions as children have limited attention spans and can only remain focused and cooperative for a limited duration, even when dental assistants and practitioners make efforts to engage and entertain them. The level of stress experienced by dental students during their paediatric dentistry training seems to depend also on the type of procedures they have to carry out. Our study confirmed that administering local anaesthesia in children induces elevated levels of stress in dental students. It can be explained by the fact that children often exhibit anxiety, making it challenging for students to administer the anaesthetic precisely. Also, Alazmah at al. reported that dental students were quite stressed during performing that procedure in children. Additionally, when the distribution of the respondents’ answers according to the most stressful procedures, was analysed giving local anaesthesia was listed in second place, and it was preceded only by managing the child’s behaviour 22 . Similarly, previous studies evaluated that the procedure of administering local anaesthesia has been a strong stressor for dentists, since 18.8% of 711 dentists participating in the study of Simon et al. reported that constant stress felt during the administration of injections causes them to reconsider dentistry as a career, whereas only 2% had no negative reaction to this aspect of dental practice 40 . Surprisingly the study of Davidovich et al. showed that compared to general practitioners and specialists, dental students reported a low level of stress during the injection of anaesthesia. According to the authors it might have been due to the fact that students participating in the study treat only cooperative children and they haven’t had experience in treating anxious children. Additionally, working under the supervision of a senior dentist who can help and finish the procedure in case of failure, might have given students a sense of confidence 23 . In our study, analysis of ratings of stress level using 5-point Likert type-scale showed that endodontic treatment was the most stress provoking paediatric procedure. Moreover, the self-reported stress score was significantly higher in Polish students than in international students. Alazmah et al. used a 3-point scale for rating stress level and observed that 51.1% of students found performing pulp therapy in children to be quite stressful 23 . The discrepancy in stress levels during endodontic procedures between Polish and English division’s students may be partially explained by the lower overall stress levels of foreign students or may be related to the fact that, due to the language barrier, these students receive more support from supervisors and assistance in managing children's behaviour during difficult endodontic procedures. This hypothesis may be supported by the observation that international students experience more stress than Polish students during simple procedures such as impregnation or fluoride application, when much less assistance is provided by the senior dentist. Caries removal in the mandible seems to be less stressful for both national and international responders of the present survey. Also, Farokh-Gisour and Hatamvand who examined dental stress level during performing paediatric procedures by dental students and dentists in Iran observed that preparation of the cavity for mandibular teeth is less stressful, and it was suggested to be due to the direct vision and easy access 24 . Paediatric dentistry is a demanding specialty that presents numerous stressors which encompass, procedural complexity, some differences between treatment methods in adolescent patients and in adults, behavioural management of anxious children, as well as other factors like parental expectations and the pursuit of excellence in treatment. Due to these challenges, students infrequently opt for specialization in this area of dentistry 41 . Our study confirmed that paediatric dentistry is assessed as a difficult specialty by the majority of both national and international students. Unfortunately only, 30% of international and 22.66% of Polish students consider working in the field of paediatric dentistry after graduating. Also, the study of Alazmah et al. showed that only a third of 5 th− year Indian students want to pursue paediatric dentistry as a specialty 22 . Data from the surveys on US senior students showed even lower interest in this specialty. Immediate postgraduation plans to choose paediatric dentistry specialty have 6.1% of female students and 1.5% of male students, and regarding personal quality of life, only 5% of respondents believed that paediatric dentistry offers the best future. Additionally, just 3% thought this specialty provides the best salary prospects 41 . CONCLUSION The majority of Polish students and those studying dentistry in English experienced moderate to high stress during clinical practice in paediatric dentistry, which, in their opinion, hurt the quality of their clinical performance. Students with higher PS levels feel more stress when performing dental procedures on children. Understanding the nature of stress related to clinical training among dental students, particularly those facing language-related challenges, is crucial for developing support systems that can help mitigate the detrimental effects of stress on their well-being and increase students’ motivation and interest in pursuing a future practice in paediatric dentistry. STUDY LIMITATION The result was obtained from a single-center study, so the findings might not necessarily be representative of the entire senior undergraduate dental student population in Poland. The other concern was the small number of participants mainly due to the low response rate of Polish division students. Even though the response rate was much higher among international students, there were only 50 students (25 from 4th and 5th year) in the academic year 2022/2023. Beside non-response bias, a potential limitation is the use a bespoke paediatric dentistry stress questionary which can be bias inherent, but there are no established psychological questionnaires to asses stressors related to paediatric dentistry training. Nevertheless the result of this survey are in line with other research on stress perceived in undergraduate students during performing paediatric dental procedures. This study does not provide data on changes in stress levels over time. However, the implication derived from the present study may be important for university faculty, as they might use the results to improve study conditions and lessen students’ stress related to clinical practice. In addition, this study compared overall perceived and clinical-related stress within the same cohort of dental students, which is rare in the literature. Declarations Author Contribution AB-Z and JD designed the study, collected and analyzed the data, did the literature search, and wrote the draft of the paper. Both authors reviewed the manuscript.equal co-first authorship Acknowledgement We sincerely thank senior dental students at the Medical University of Lodz who gave their time to participate in the survey, and Professor Joanna Szczepańska (the Head of the Department of Pediatric Dentistry MUL) for her advice and support. Data Availability DATA AVAILABILITY STATEMENTDetailed survey data are available from the corresponding author upon request. References Lazarus, R. S. & Folkman, S. Stress, appraisal, and coping (Springer publishing company, 1984). Lazarus, R. S. & Folkman, S. Transactional theory and research on emotions and coping. EJP 1 , 141–169 (1987). Schmitter, M., Liedl, M., Beck, J. & Rammelsberg, P. Chronic stress in medical and dental education. Med. Teach. 30 (1), 97–99 (2008). Alotaibi, S., Deligianni, E., Riley, P. & Glenny, A. M. Prevalence and Incidence of Stress Among UK Dental Students: A Systematic Review and Meta-analysis. Int. Dent. J. S0020–6539 ( 24)01614-9 10.1016/j.identj.2024.11.019 Humphris, G. et al. Psychological stress in undergraduate dental students: baseline results from seven European dental schools. Eur. J. Dent. Educ. 6 , 22–29 (2002). Drachev, S. N. et al. Perceived Stress and Associated Factors in Russian Medical and Dental Students: A Cross-Sectional Study in North-West Russia. Int. J. Environ. Res. Public. Health . 17 (15), 5390. 10.3390/ijerph17155390 (2020). Alzahem, A. M., van der Molen, H. T., Alaujan, A. H., Schmidt, H. G. & Zamakhshary, M. H. Stress amongst dental students: a systematic review. Eur. J. Dent. Educ. 15 (1), 8–18 (2011). Sanders, A. E. & Lushington, K. Sources of stress for Australian dental students. J. Dent. Educ. 63 (9), 688–697 (1999). García-Campayo, J., Puebla-Guedea, M., Herrera-Mercadal, P. & Daudén, E. Burnout Syndrome and Demotivation Among Health Care Personnel. Managing Stressful Situations: The Importance of Teamwork. Actas Dermosifiliogr . 7 (5), 400–406 (2016). Collin, V., O'Selmo, E. & Whitehead, P. Stress, psychological distress, burnout and perfectionism in UK dental students. Br. Dent. J. 229 (9), 605–614. 10.1038/s41415-020-2281-4 (2020). Jiménez-Ortiz, J. L. et al. Emotional exhaustion, burnout, and perceived stress in dental students. J. Int. Med. Res. 47 (9), 4251–4259 (2019). Elani, H. W. et al. Systematic Review of Stress in Dental Students. J. Dent. Educ. 78 (2), 226–242 (2014). Gorter, R. et al. Psychological stress and health in undergraduate dental students: fifth year outcomes compared with first year baseline results from five European dental schools. Eur. J. Dent. Educ. 12 (2), 61–68 (2008). Lin, X. J. et al. Stress and its association with academic performance among dental undergraduate students in Fujian, China: a cross-sectional online questionnaire survey. BMC Med. Educ. 20 (1), 181. 10.1186/s12909-020-02095-4 (2020). Veerkamp, J. S. J. & Wright, G. Z. Introductory remarks In Behavior Management in Dentistry for Children 2nd edition (ed. Wright, G.Z. Kupietzky, A) 1–9Willey Backwell, (2014). Singh, A., Jindal, R., Bhardwaj, A. & Veeresha, K. L. A preliminary study of perceived stress among dental undergraduate students in rural Haryana. J. Oral Health Res. 2 (3), 91–95 (2011). Acharya, S. Factors affecting stress among Indian dental students. J. Dent. Educ. 67 (10), 1140–1148 (2003). Juszka, Z. et al. Assessment of stress load among Polish and English dental students’ divisions in Poland. J. Stomatol. 74 (3), 177–187 (2021). Ali, S. et al. Psychological Impact of the COVID-19 Pandemic on Students, Assistants, and Faculty of a Dental Institute of Saudi Arabia. Int. J. Environ. Res. Public Health 18(24):13366 0.3390/ijerph182413366 (2021). Divaris, K. et al. The academic environment: the students' perspective. Eur. J. Dent. Educ. 12 (Suppl 1), 120–130 (2008). Polychronopoulou, A. & Divaris, K. Dental students' perceived sources of stress: a multi-country study. J. Dent. Educ. 73 (5), 631–639 (2009). Alazmah, A. at al. Level of Stress among Final Year Dental Students while Performing Paediatric Dentistry Procedures in Riyadh City- A Cross-sectional Study. J. Clin. of Diagn. Res. 14(11):ZC24-ZC28 (2020). Davidovich, E., Pessov, Y., Baniel, A. & Ram, D. Levels of Stress among General Practitioners, Students and Specialists In Pediatric Dentistry during Dental Treatment. J. Clin. Pediatr. Dent. 39 (5), 419–422 (2015). Farokh-Gisour, E. & Hatamvand, M. Investigation of stress level among dentistry students, general dentists and pediatric dental specialists during performing Pediatric Dentistry in Kerman, Iran, in 2017. Open. Dent. J. 12 (1), 631–637 (2018). Higgins, M. CHDWB Codebook Chap. 5 Perceived Stress Scale. https://melindahiggins2000.github.io/CHDWBCodebook/pss.html#pss-14-items Cohen, S., Kamarck, T. & Mermelstein, R. A global measure of perceived stress. J. Health Soc. Behav. 24 , 385 (1983). Lee, E. H., Chung, B., Suh, C. H. & Jung, J. Y. Korean versions of the Perceived Stress Scale (PSS-14, 10 and 4): Psychometric evaluation in patients with chronic disease. Scand. J. Caring Sci. 29 (1), 183–192 (2015). She, Z. et al. Three Versions of the Perceived Stress Scale: Psychometric Evaluation in a Nationally Representative Sample of Chinese Adults during the COVID-19 Pandemic. Int. J. Environ. Res. Public. Health . 18 (16), 8312. 10.3390/ijerph18168312 (2021). Ruisoto, P., López-Guerra, V. M., Paladines, M. B., Vaca, S. L. & Cacho, R. Psychometric properties of the three versions of the Perceived Stress Scale in Ecuador. Physiol. Behav. 224 , 113045. 10.1016/j.physbeh.2020.113045 (2020). Mikolajczyk, R. T., Ansari, E., Maxwell, A. E. & W., & Food consumption frequency and perceived stress and depressive symptoms among students in three European countries. Nutr. J. 8 , 31. 10.1186/1475-2891-8-31 (2009). Humphris, G. M. & Peacock, L. Occupational stress and job satisfaction in the community dental service of North Wales: a pilot study. Community Dent. Health . 10 , 73–82 (1992). Wilson, R. F. et al. Perceived sources of occupational stress in general dental practitioners. Br. Dent. J. 184 , 499–502 (1998). Yadav, V. et al. Emotional Intelligence and Perceived Stress among Dental Undergraduates in Delhi. Int. J. Clin. Pediatr. Dent. 13 (4), 344–347 (2020). STADA Health Report. (2022). https://www.stada.com/media/7197/health-report-2022_final.pdf Kaipa, S., Margabandhu, S., Fareed, N. & Kumar, K. Perceived source of stress among dental students in South India. Ann. Essence Dent. 4 (1), 43–51 (2012). Kumar, S. et al. Perceived sources of stress amongst Indian dental students. Eur. J. Dent. Educ. 13 , 39–45 (2009). Morse, Z. & Dravo, U. Stress levels of dental students at the Fiji School of Medicine. Eur. J. Dent. Educ. 11 (2), 99–103 (2007). Leith, R., Olegário, I. C. & O'Connell, A. C. Clinical experience of undergraduate dental students in paediatric dentistry: A 5-year cross-sectional study. Eur. J. Dent. Educ. 27 , 941–948 (2023). Ayers, K. M., Thomson, W. M., Newton, J. T. & Rich, A. M. Job stressors of New Zealand dentist and their coping strategies. Occup. Med. 58 (4), 275–281 (2008). Simon, J. F., Peltier, B., Chambers, D. & Dower, J. Dentists troubled by the administration of anesthetic injections: long-term stresses and effects. Quintessence Int. 25 , 641–646 (1994). Dhima, M., Petropoulos, V. C., Han, R. K., Kinnunen, T. & Wright, R. F. Dental students' perceptions of dental specialties and factors influencing specialty and career choices. J. Dent. Educ. 76 (5), 562–573 (2012). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6238639","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":486558871,"identity":"dfb9e580-6283-4f2f-9ece-e619ed943ca6","order_by":0,"name":"Agnieszka Bruzda-Zwiech","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Lodz","correspondingAuthor":true,"prefix":"","firstName":"Agnieszka","middleName":"","lastName":"Bruzda-Zwiech","suffix":""},{"id":486558874,"identity":"3f4a8281-24a4-4d1e-8eea-ba74cc150be7","order_by":1,"name":"Julia Durka","email":"","orcid":"","institution":"Medical University of Lodz","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Durka","suffix":""}],"badges":[],"createdAt":"2025-03-16 16:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6238639/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6238639/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87362870,"identity":"3491a3df-9cd1-47dd-a9e6-c33eaddf69c7","added_by":"auto","created_at":"2025-07-23 05:57:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47806,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of stress levels when performing dental treatment on children among students of the English and Polish divisions.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/ffffc12bc75c204d62711a05.jpg"},{"id":87362872,"identity":"63e8c808-b039-4baa-ab5e-9187dd6edc49","added_by":"auto","created_at":"2025-07-23 05:57:57","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":85704,"visible":true,"origin":"","legend":"\u003cp\u003eStudents agreement (rated with 5- point Likert scale) to particular statements, surveyed according to the study groups.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/6be44696fe5fdbbc48dec04c.jpg"},{"id":87363435,"identity":"fd8448f5-2ff9-452e-8df5-f7a9224cdfd6","added_by":"auto","created_at":"2025-07-23 06:05:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":56625,"visible":true,"origin":"","legend":"\u003cp\u003eRanking of stress-inducing factors by divisions of Dentistry- English and Polish\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/ac074b74c7819127e0e497cb.jpg"},{"id":87363445,"identity":"f24f15dc-cf7d-4c3d-8568-0001555d2789","added_by":"auto","created_at":"2025-07-23 06:05:57","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":204333,"visible":true,"origin":"","legend":"\u003cp\u003eStudents answers to the question “Do you think paediatric dentistry is an easy specialty?\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/437d5282d1a0a04279b184e2.jpg"},{"id":87362876,"identity":"89e78e7d-3ebd-4efe-a43b-04121776bed2","added_by":"auto","created_at":"2025-07-23 05:57:57","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":56083,"visible":true,"origin":"","legend":"\u003cp\u003eStudents interest in working in the field of paediatric dentistry after graduating\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/112731246611dbdf450238ce.jpg"},{"id":87364195,"identity":"0a3ae940-54d8-4598-ada9-b79208160ee6","added_by":"auto","created_at":"2025-07-23 06:13:57","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":297249,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of perceived stress levels in subgroups of students undertaking education at English and Polish Divisions. PSS-14 scores categories as Low Stress (scores 0 - 18), Moderate Stress (scores 19 - 37), High Stress (scores 38 - 56).\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/2792640b10c715aa0fd81487.jpg"},{"id":87467190,"identity":"d53aeb00-9e8c-4910-8770-1b2f21f7865e","added_by":"auto","created_at":"2025-07-24 08:02:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1434190,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6238639/v1/ed0c4b87-b3d8-4a22-931c-8b359ea1a03a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring stressors in paediatric dentistry clinical training among Polish and International dental students at the Medical University of Lodz","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAs per Lazarus and Folkman's perspective, stress can be defined as a specific interaction between an individual and their surroundings, wherein the person perceives it as placing demands or challenges that exceed their capacity to deal with it and pose a threat to their overall well-being, psychologists also suggested that the way we would interpret an event and emotions that arise from it may have a greater impact on our stress levels than the event itself \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Stress is a pervasive factor among students of all types, particularly manifesting in medical and dental students who contend daily with demanding tasks, vast amounts of study materials, and profound sense of the responsibility associated with patient care \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Remarkably, stress levels among dental students have been observed to surpass those among medical students\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This discrepancy may be attributed to factors such as stringent time constraints, the relentless pursuit of aesthetic treatment precision, exacting treatment standards, and intense competitiveness within the field of dentistry. Unfortunately, stress does not go unnoticed; it can persist even after the stressor is removed, affecting students' mental health, eroding their confidence, and significantly influencing their educational performance \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. High levels of stress and persistent stress exposure may culminate in burnout syndrome, characterized by the experience of long-term work-related exhaustion and diminished interest low personal accomplishment \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e.\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Although burnout refers to a long-term process, it is apparent amongst students too, especially those in their later years of study \u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Chronic stress may also encompass a spectrum of health impacts, including physical ailments, such as digestive problems, skin and cardiovascular diseases and psychological manifestations, including hostility and cynicism \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Furthermore, the dental profession, which students will be pursuing after graduation, is considered to be one of the most stressful health professions, among others due to intense interaction between dentist and patient \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eStress in students may have many sources such as student-related, academic (amount and difficulty of classwork, exams and grades) or faculty-related factors, but senior students additionally face the challenges of clinical training \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. It is also worth noting extra stressors e.g. the aspects of providing oral care to children or differences in residency status that could impact a particular demographic: students studying overseas. Effective communication is crucial when interacting with patients, as it not only enables the collection of vital information about their health but also helps put them at ease. For students who do not fluently speak the language of the country in which they reside, interacting with native patients can present a challenge. Moreover, the so-called paediatric dentistry treatment triangle, which includes the development of the doctor-patient and doctor-patient\u0026rsquo;s parent/caregiver relationships, instead of offering a sense of comfort, could potentially add stress for the student providing the treatment to children \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In a demanding role such as being an undergraduate dentist, where one must diagnose and treat patients flawlessly while simultaneously preparing for exams, this could potentially emerge as a notable stress-inducing factor, amplifying the overall stress experienced. Though numerous studies have explored the stress experienced by dental students \u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, there has been very limited research focused on stressors related to paediatric dentistry training \u003csup\u003e\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Additionally, due to our best knowledge, no study has compared stress while performing paediatric dental treatments between international and native students in Poland.\u003c/p\u003e\u003cp\u003eThe Medical University of Lodz offers a 5-year Dentistry program in Polish language, as well as English-taught dentistry program, that has been available for over 20 years. The program of Polish and English divisions of Dentistry at the Faculty of Medicine culminates in the degree of Doctor of Dental Medicine (DMD). Currently, the English division of Dentistry has an international community with students from all over the world. Curriculums of Paediatric Dentistry courses for both Polish and international students are identical, except for the language in which they are taught.\u003c/p\u003e\u003cp\u003eThe objective of our study was therefore to investigate the level of experienced stress and possible stress-provoking factors related to clinical paediatric dentistry training in undergraduate 4\u003csup\u003eth\u0026minus;\u003c/sup\u003eand 5\u003csup\u003eth\u0026minus;\u003c/sup\u003eyear dental students, and to examine the obtained data in terms of differences between senior students of the English and Polish divisions of Dentistry. Furthermore, the study aimed to assess if overall perceived stress load has an influence on experienced stress when providing dental treatment in children and to investigate the desire of dental students to choose paediatric dentistry specialty as the future career.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eIn this cross-sectional study anonymous questionnaire was sent via e-mail to 4\u003csup\u003eth\u0026minus;\u003c/sup\u003eand 5th -year students of the English an Polish divisions of Dentistry during the summer semester of the academic year 2022\u0026ndash;2023.\u003c/p\u003e\u003cp\u003e The study protocol was approved by the Medical University of Lodz Bioethics Committee, Resolution Number RNN 32/23/KE. The survey was conducted in compliance with the principles of the revised 2013 Helsinki Declaration. The research was carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eThe questionnaire was prepared using the Microsoft Forms program and the link was sent to student\u0026rsquo;s official email accounts addresses in March 2023, thus allowing for the completion within one semester. E-mails with invitation to participate in the survey were sent to all international and Polish senior dental students with a cover letter containing the description of the study purpose, the voluntary, anonymous nature of the study participation, and the link to the questionnaire in English and Polish language, respectively. Upon clicking the provided link, students were directed to the questionnaire. Although, the survey was anonymous, students were asked at the beginning of the questionnaire to confirm that they agreed to participate anonymously in the survey. Informed consent was obtained from all participants. Respondents were not required to provide any personal information, such as their names or surnames, during the questionnaire completion process. This measure was implemented to guarantee the anonymity and confidentiality of the participants. Furthermore, we aimed to prevent students from providing biased responses due to concerns about their answers being visible to any of their teachers. The questionnaire was structured into three segments. The initial section comprised questions aimed at gathering demographic details: study year, age, and gender, if desired. The core part of it contained bespoke questions regarding clinical factors. Students were asked to determine using a 5-point Likert - type scale (ranging from 1 to 5) the following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ethe level of self-reported stress when performing dental treatments on paediatric patients in general and when performing particular (12 selected) procedures; For analysis, the scores were interpreted: 1- no stress, 2- mild stress, 3- moderate stress, 4-much stress, 5-extreme stress;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ethe influence of the presence of the child's parent during treatment on the level of experienced stress;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ehow the knowledge of the Polish language, allowing for effective communication with patients, affects the treatment time and if it has an impact on achieving treatment success in the dental treatment of children;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ethe impact of preclinical training as well as the number of times they performed the given clinical procedure on their level of confidence in performing paediatric dentistry procedures;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ethe level of agreement (from strongly disagree-1 to strongly agree \u0026minus;\u0026thinsp;5) to selected statements about the influence of stress on their clinical work quality, and the children\u0026rsquo;s age as factors exacerbating respondees\u0026rsquo; stress during practical paediatric dental training.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFurthermore, students were asked to:\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003erank the potential stressors during dental treatment in children including the supervisor's attitude, patient's attitude, time pressure, language barrier, practical skills requirements, theoretical knowledge requirements and strive for perfection in order from the most onerous to the least\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eanswer questions: \u0026ldquo;Do you think paediatric dentistry is an easy specialty? Would you consider working in the field of paediatric dentistry after graduating?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eTo evaluate the level of overall perceived stress (PS) in students the concluding section of the survey included the Perceived Stress Scale (PSS-14), the internationally recognized self-report psychological assessment tool comprising of seven negative (representing perceived helplessness) and seven positive items (representing self-efficacy) summarized in 14 questions. Respondents were asked how often during the last month they felt or thought a certain way when faced with different situations in their life, and each of the questions required the student to provide a rating on a five-point Likert scale of 0 to 4, with options: \u0026ldquo;never\u0026rdquo;, \"almost never\", \"sometimes\", \"fairly often\", and \"very often,\" as appropriate. PSS-14 scores are obtained by reversing the scores on the seven positive items; therefore, they are recoded (0\u0026thinsp;=\u0026thinsp;4, 1\u0026thinsp;=\u0026thinsp;3, 2\u0026thinsp;=\u0026thinsp;2, 3\u0026thinsp;=\u0026thinsp;1, 4\u0026thinsp;=\u0026thinsp;0), and then summing across all items is done. Total scores range from 0 to 56 and are categorized as Low Stress (scores 0\u0026ndash;18), Moderate Stress (scores 19\u0026ndash;37), and High Stress (scores 38\u0026ndash;56), as coded earlier by Higgins \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. The Perceived Stress Scale-14 is a commonly utilized tool for gauging the extent to which individuals perceive life situations as laden with stress. The scale originally developed by Cohen et al. (1983), was translated into more than 20 languages \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. PSS was used for stress perception assessment in research worldwide \u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, including those on dental students \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Its psychometric properties in assessing perceived psychological stress have been satisfactorily verified \u003csup\u003e\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, and also the Polish version, used in a study of 591 university students, showed good internal consistency and reliability \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using Statistica for Windows software (version 13.3). The normality of distribution was checked by the Shapiro-Wilk test. The results were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Comparisons between the study subgroups were performed using the t- test. Correlations were assessed by correlation test (r). Differences were considered significant if p was less than 0.05. Additionally, descriptive analysis for categorical variables was performed (frequency, percentage were calculated). A Chi-squared test was used to analyse the differences in categories of perceived stress between the groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe overall response rate was 38.59% (115 of 298 potential participants). A higher response rate was among international students than Polish one (40 of 50 students \u0026minus;\u0026thinsp;80% versus 75 of 248\u0026ndash;30.24%). The mean age of the respondents was 24 years (ranging from 22\u0026ndash;30 years) and was 23.5 vs. 23.66 for native and international students, respectively. Among the participants, 70.43% (n\u0026thinsp;=\u0026thinsp;81) of the respondents were female and 27.83% (n\u0026thinsp;=\u0026thinsp;32) were male, and 2 students (1.74%) preferred not to say their gender. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the distribution of respondents by year of study and gender.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe characteristic of the study group.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivision\u003c/p\u003e\u003cp\u003eof Dentistry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcademic year level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrefer not to say\u003c/p\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSum\u003c/p\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOVERALL\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePolish division\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4th year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003cp\u003e(65.22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5th year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEnglish division\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4th year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003cp\u003e(34.78%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5th year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOVERALL n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (27.83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81 (70.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (1.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e115 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e115\u003c/p\u003e\u003cp\u003e(100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEvaluation of student responses, given using a 5-point scale, regarding stress experienced when performing procedures on paediatric patient showed that the mean rating of stress was 3.23 vs 2.95 for the English- and Polish-division students. The stress provoked by providing dental treatment for children did not differ significantly between both groups, and neither were found any differences between male and female students, and when comparing the study years. 98.2% of Polish and 90% of international students reported experienced stress when performing dental procedures in children. Stress level was most often scored 3- moderate stress by international students (40%) and 4 -much stress by native students (34.66%). None of the responders studying at the English division rated stress as extreme, while at the Polish division score 5 was given by 6 students (8%). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents mean stress scores for particular dental procedures assessed using a 5-point scale, surveyed according to the study groups. Both Polish students and those studying in English rated stress as being the highest while performing endodontic procedures, however, self-reported mean stress score was significantly higher in Polish students. For both groups of students, the second most stressful procedure was administering local anaesthesia to children. Native students perceive significantly higher stress also during caries cavity preparation in mandibular teeth and while restoring the cavity with composite resin. In contrast, procedures such as topical fluoride application or silver nitrate treatment of early childhood caries and distinguishing between milk and permanent teeth while carrying out dental examination in children with mixed dentition were considered more stressful for students studying English. No statistically significant differences were observed between international and students Polish for other mentioned in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e procedures such as local anaesthesia injection, taking dental impression or simple extraction of milk teeth. Caries removal in mandibular teeth were scored by both groups of students as significantly more stressful than cavity preparation in maxillary teeth (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean stress scores for particular dental procedures assessed using 5-point scale, surveyed according to the study groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProcedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolish division n\u0026thinsp;=\u0026thinsp;75\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEnglish division\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;40,\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSignificance\u003c/p\u003e\u003cp\u003e(t, p)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003emean value \u0026plusmn; SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003emean value\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistinguishing between permanent and deciduous teeth while caring out dental examination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.107\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et= -2.45957, p\u0026thinsp;=\u0026thinsp;0.015426\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdministration of local anaesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;1.936994, p\u0026thinsp;=\u0026thinsp;0.0552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaries removal in maxilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.226\u0026thinsp;\u0026plusmn;\u0026thinsp;1.072 *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.825\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;1.824, p\u0026thinsp;=\u0026thinsp;0.070767\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaries removal in mandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.989 *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8 5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.098 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et\u0026thinsp;=\u0026thinsp;3.525, p\u0026thinsp;=\u0026thinsp;0.000612\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlass ionomer placement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.027\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et=-0.107902, p\u0026thinsp;=\u0026thinsp;0.914265\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComposite placement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.507\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.025\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et\u0026thinsp;=\u0026thinsp;2.332343, p\u0026thinsp;=\u0026thinsp;0.021453\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFluoride application\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.133\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.475\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et=-2.60675, p\u0026thinsp;=\u0026thinsp;0.010373\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSilver nitrate impregnation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.747\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.325\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et=-2.53885, p\u0026thinsp;=\u0026thinsp;0.012482\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect pulp capping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.347\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;0.622980, p\u0026thinsp;=\u0026thinsp;0.534553\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndodontic treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.675\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003et\u0026thinsp;=\u0026thinsp;3.339, p\u0026thinsp;=\u0026thinsp;0.001139\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSimple deciduous tooth extraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;1.163, p\u0026thinsp;=\u0026thinsp;0.247\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaking impressions with alginate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.707\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.475\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;0.978, p\u0026thinsp;=\u0026thinsp;0.330\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e* t\u0026thinsp;=\u0026thinsp;3,955, p\u0026thinsp;=\u0026thinsp;0,00018 ; ** t\u0026thinsp;=\u0026thinsp;3,76, p\u0026thinsp;=\u0026thinsp;0,00033\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLooking for additional factors exacerbating stress, students\u0026rsquo; responses to open question (\u0026ldquo;How much does the presence of a child's parent during treatment affect/increase the level of stress you feel?\u0026rdquo;) were analysed, and no statistically significant differences were found between Polish students and those studying in English, with mean score of 3.02 vs 2.95. In both groups the most often given scores were 3 and 4. However, in the group of international students, the same percentage of responders reported moderate and much stress (26.66%) while of national students 32.5% reported much stress and 27.5% moderate stress when having the patient guardian in the clinic room while performing dental procedures on the child.\u003c/p\u003e\u003cp\u003eBoth groups of students agreed with the statement that knowledge of the language the patient communicates in has a significant impact on reducing the length of the visit (mean level of agreement in 5-Likert\u0026rsquo;s scale was 4.43 for Polish residents and 4.08 for international students, respectively). Similarly, students agreed that the ability to communicate in the patient's language contributes to success of dental treatment in children (mean level of agreement in 5-Likert\u0026rsquo;s scale was 4.41 for Polish residents and 4.13 for international students, respectively). None of the statistically significant differences were found for the above comparisons.\u003c/p\u003e\u003cp\u003ePreclinical training seems to have stronger influence on international students' confidence in performing clinical procedures (mean 3.55 vs 4.28 for Polish and English division students for p\u0026thinsp;=\u0026thinsp;0.0029 and t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.046). While for Polish students the number of times they perform the given clinical procedure seems more affect their confidence level (mean 4.73 vs 4.3 for Polish and international students for p\u0026thinsp;=\u0026thinsp;0.01 and t\u0026thinsp;=\u0026thinsp;2.0461).\u003c/p\u003e\u003cp\u003eAnalysing students' agreement levels with the statement about the influence of a child\u0026rsquo;s age as a factor exacerbating stress during practical training showed that the level of experienced stress depends on patient\u0026rsquo;s age \u0026minus;\u0026thinsp;42.5% of students enrolled in the English-taught dentistry program and 60% native students agreed or strongly agreed that the younger the patient the more stressed they felt. A higher percentage of Polish than international students agreed or strongly agreed that the level of stress they experience depends on the age of the patient (57.33% vs 32.5%). 60% of native and 52.5% of international responders share the opinion that stress affects the quality of their work. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows students\u0026rsquo; agreement rated with 5- point Likert type scale to mentioned statements.\u003c/p\u003e\u003cp\u003ePotential stressors ranked by respondents in the online survey, in order from top to bottom stressor are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Patient's attitude was placed at the top of the stressors hierarchy by Polish students, followed by supervisor\u0026rsquo;s attitude, whereas in international students the hierarchy was reversed, and these factors were ranked second and first place, respectively. However, time pressure was mentioned in third place in both groups of students. Different from Polish students, international students ranked higher the language barrier than theoretical knowledge and practical skills.\u003c/p\u003e\u003cp\u003eMost students do not assess paediatric dentistry as an easy speciality (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and only 12 of 40 (30%) international students 17 of 75 (22.6%) Polish students showed interest in working in the field of paediatric dentistry after graduating (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe mean of the PSS-14 scores was 34.106\u0026thinsp;\u0026plusmn;\u0026thinsp;7.87 (minimum 19, maximum 46) and 27.575\u0026thinsp;\u0026plusmn;\u0026thinsp;6.24 (minimum 11 maximum 42) for Polish students and those studying in English, respectively. In both groups the mean score responded to moderate stress level. There were statistically significant differences in perceived stress (PS) between Polish and international students (34.106 vs 27.575 t\u0026thinsp;=\u0026thinsp;4.68 p\u0026thinsp;=\u0026thinsp;0.000), also when analysing the score according to genders (34.16 vs. 28.17, t\u0026thinsp;=\u0026thinsp;3.15, p\u0026thinsp;=\u0026thinsp;0.002 for comparison between women and 33.83 vs. 26.80, t\u0026thinsp;=\u0026thinsp;2.60, p\u0026thinsp;=\u0026thinsp;0.014 for comparison between males, respectively).\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows distribution of stress categories (low, moderate and high stress) among the study groups.\u003c/p\u003e\u003cp\u003eWhen comparing the mean score for PSS between females and males within the groups, there were no statistically significant differences for both Polish and international students (34.16 vs 33.83 and 28.16 vs 26.8, respectively). When examining of the PS according to the year of the study we found higher stress in 4th -year Polish students comparing to students enrolled in the English division. Among international students lower stress was observed in 4th -year compared to those of 5th year (34.54 vs 25.59 t\u0026thinsp;=\u0026thinsp;4.686 and 25.59 vs 30.0 t= -2.347, respectively). No statistically significant differences were shown for comparison of PS between 5th -year students of both study groups (33.88 vs 30.0) and between Polish 4th -and 5th -year students (34.54 vs 33.88)\u003c/p\u003e\u003cp\u003eA positive correlation was found between PPS-14 score and level of stress for carrying out dental treatment in children for both Polish and international students (r\u0026thinsp;=\u0026thinsp;0.3 for p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and r\u0026thinsp;=\u0026thinsp;0.32 for p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIt has been reported previously that dental education is known to be highly demanding and induces considerable stress on students \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Clinical training seems to be the most critical phase of dental education as students are expected to acquire a wide range of knowledge and skills that should help them succeed in their studies and in providing dental treatment to their patients \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Moreover, the clinical years has been shown to be more stressful than the pre-clinical years \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Data from the literature suggest that understanding of how students experience and perceive their studies might be helpful for creating a positive academic environment \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e\u003cp\u003eIn this study, the PSS-14 was employed to measure the general stress load in 4th and 5th -year students and Likert-like scale to pinpoint the specific paediatric dental procedures that exert the most significant stress on students, as that information may be of value not only from psychological point of view, but also might be highly relevant for faculty teachers to guide them on how to support students during clinical courses. In present study, the mean score of overall stress reported by both Polish and international students was within the range of moderate stress level. It is in accordance with results of the surveys on dental students in the UK, North-West Russia and China, in which the shortened version of the PSS with 10 items was used \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, we observed higher percentage of both native and international students with high level of stress in (22.5% and 37%, respectively), than it was reported for Russian students (4.9%), but lower comparing to UK dental students (56%) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. What\u0026rsquo;s more Juszka et. Al, who also used the PSS scale, reported a moderate level of perceived stress among 4th - and 5th -year students. Similarly to our survey, the authors found significantly higher stress levels in Polish students than in international students enrolled in the English division of Dentistry, but only when analysing all students together and specifically for 4th-year students. In contrast to our study, the level of stress among 5\u003csup\u003eth\u0026minus;\u003c/sup\u003e year students was higher in international students than in Polish students \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn our study, we observed only that the level of stress increased significantly in the final year international students compared to 4th -year ones, while Polish 4\u003csup\u003eth\u0026minus;\u003c/sup\u003e year students scored higher than those of 5th year. Also Sanders et al. noted in the group of Australian dental students peaking of the stress at 4th -year of study.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Furthermore, in the survey conducted by Gorter et al. 5\u003csup\u003eth\u0026minus;\u003c/sup\u003eyear students showed relatively high mean MBI (The Maslach Burnout Inventory) scores, and negative development from year one to year five in relation to emotional exhaustion and psychological distress was observed \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. According to Sanders et al. for senior students, the accumulative effect of stress is also confounded by the increased technical difficulty in performing clinical tasks \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. This seems to be in line with our observations, as we found a positive correlation between the PPS score and the level of stress experienced when providing dental treatment to children for both native and international students. The increase in perceived daily stress level can be also explained by the findings of other authors that final year students showed greater anxiety about the future \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSimilarly to the study of Cohen we found no significant difference in PSS scores between male and female students in any of the survey group \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Also, other studies conducted in several European dental schools, as well as in China and Mexico didn\u0026rsquo;t find gender differences in perceived stress assessed using PSS or the Dental Environment Stress (DES) scales \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. In addition, Wilson et al. assessed stress among recently graduated dentists and the ones in practice for a longer time and described gender differences only to be significant amongst the latter group \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. However, data on disparity in perceived stress between genders are not unanimous. Some previous studies that enrolled students of all years noted greater perceived stress scores in female dental students \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. In contrast, research conducted in India showed that male dental students exhibited higher levels of stress than women did which might be associated with sociocultural influences \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. However, it has been stated that gender differences in the dental profession would diminish as more females would take on an assertive role in society \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe mean PSS-14 score in the sample of senior students enrolled in the English division (25.59) in our study was comparable to the score reported by Singh et al. for last year\u0026rsquo;s dental students in India (26.86), and slightly higher than that reported by Cohen for the sample of College students in the USA (23.67) \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. However, Polish students reported much higher stress level (34.54). The STADA Health Report 2022 online survey of almost 30,000 respondents in 15 European countries showed that Polish adults are most susceptible to feel burnout compared to the rest of Europe. In Poland, 70% of responders reported they have experienced feelings of burnout at least once in their lifetime. The youngest age group surveyed (18-24-year-olds) were shown to be especially susceptible to it \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Similar PSS scores to our survey were reported only for senior undergraduate dental students in Saudi Arabia during COVID-19 pandemic (31.33, 33.04 and 34.41 for 4th -, 5th - and 6th - academic year students, respectively) \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. So, it cannot be excluded that pandemic made students more stressed. Sanders et al. who examined stress level in dental students using DES scale found in category of clinical training no statistical differences in stress score between Australian and international students, however difficulty in learning clinical procedures was ranked higher in stressors\u0026rsquo; hierarchy by national than international students. The authors showed higher mean score for international students in comparison to Australian students, when sources of stress such as self-efficacy beliefs, faculty and administration; and peer pressure were analysed. According to the authors this finding may be due cultural determinants (the fact that international students derived mainly from Asian countries) to language difficulties and acculturative adjustment \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEven in our study, we focused mainly on the particular dental procedures performed during clinical training as a source of stress, but we tried to determine also the influence of the lingual barrier in effective communication with child patients and supervisors\u0026rsquo; attitude. One of the main factors contributing to overall disappointment and the inability to achieve treatment goals with young patients could stem from poor communication, which in case of international students often results from a language barrier between the undergraduate student and the patient. In such scenarios, soothing the child and attaining the desired outcomes can prove to be challenging. Both Polish residents and international students responded that knowledge of the language that patients speak highly affects the treatment success, and additionally, international students ranked the language barrier higher in stressors\u0026rsquo; hierarchy than theoretical knowledge and practical skills requirements. The issue of language barrier previously primarily affected international students at our university, given that Polish is considered one of the most challenging languages to acquire. However, due to evolving political dynamics and recent events, it has now become a concern for domestic students as well. Since the beginning of Russian military aggression against Ukraine with the outbreak of a full-scale war in Ukraine and the subsequent massive influx of refugees from that country to Poland, the situation in medical services in Poland changed. The Ukrainian citizens who arrived in Poland on or after February 24, 2022, have the same access to medical care and have been treated like insured Polish citizens by the National Health Fund. As some of these patients and their caregivers may not yet have the proficiency to communicate effectively in Polish, also native dental students have to overcome the problems with the language barrier during providing dental treatment for children as a part of clinical training at medical Universities.\u003c/p\u003e\u003cp\u003eA systematic review of stress among dental students showed that of the clinical factors, the major stressor was fear of failure to complete clinical requirements. But, among other factors criticism by supervisors, the atmosphere created by clinical faculty, as well as contact with patients and bearing the responsibility for comprehensive patient care played also important role \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Also, our study confirms those observations as the supervisor\u0026rsquo;s attitude and patient\u0026rsquo;s attitude were placed at the top of the stressors hierarchy in both survey groups. Nevertheless, international students ranked higher on the supervisor attitude. It seems to be in line with the results of the above-mentioned study of Sanders et al. that items connected with faculty are stronger stressors for international students, despite the fact that the group evaluated by those authors was made up exclusively of students of Asian origin, and in our study, it was more multicultural \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Also, Kaipa et al. showed that 4th -year students in South India perceived the atmosphere created by clinical supervisors (particularly receiving criticism from supervisors) as the highest stress inducing factor, while in studies conducted by Kumar et al. on Indian students and Morse et al. on Fijian students, this factor was ranked third \u003csup\u003e\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. This underlines how important role plays academic teacher in creating atmosphere during clinical period of dental education. It should be also noticed that the confidence of new graduates to treat paediatric patients will be influenced by their clinical undergraduate experience \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTreating children was reported as the primary reason for the UK community dental service being so stressful \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Also, Ayera et al. showed that providing dental treatment to difficult children was the most frequently mentioned stress factor by New Zealand dentists (52%), followed by time pressure mentioned by 48% of responders\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. This stays in agreement with the results of present study since time pressure was ranked third most stress-inducing factor by both, Polish and international students. Working under time constraints, which is a common occurrence in dentistry, becomes even more pronounced when dealing with children. It is crucial to avoid prolonging treatment sessions as children have limited attention spans and can only remain focused and cooperative for a limited duration, even when dental assistants and practitioners make efforts to engage and entertain them.\u003c/p\u003e\u003cp\u003eThe level of stress experienced by dental students during their paediatric dentistry training seems to depend also on the type of procedures they have to carry out. Our study confirmed that administering local anaesthesia in children induces elevated levels of stress in dental students. It can be explained by the fact that children often exhibit anxiety, making it challenging for students to administer the anaesthetic precisely. Also, Alazmah at al. reported that dental students were quite stressed during performing that procedure in children. Additionally, when the distribution of the respondents\u0026rsquo; answers according to the most stressful procedures, was analysed giving local anaesthesia was listed in second place, and it was preceded only by managing the child\u0026rsquo;s behaviour\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSimilarly, previous studies evaluated that the procedure of administering local anaesthesia has been a strong stressor for dentists, since 18.8% of 711 dentists participating in the study of Simon et al. reported that constant stress felt during the administration of injections causes them to reconsider dentistry as a career, whereas only 2% had no negative reaction to this aspect of dental practice \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Surprisingly the study of Davidovich et al. showed that compared to general practitioners and specialists, dental students reported a low level of stress during the injection of anaesthesia. According to the authors it might have been due to the fact that students participating in the study treat only cooperative children and they haven\u0026rsquo;t had experience in treating anxious children. Additionally, working under the supervision of a senior dentist who can help and finish the procedure in case of failure, might have given students a sense of confidence \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn our study, analysis of ratings of stress level using 5-point Likert type-scale showed that endodontic treatment was the most stress provoking paediatric procedure. Moreover, the self-reported stress score was significantly higher in Polish students than in international students. Alazmah et al. used a 3-point scale for rating stress level and observed that 51.1% of students found performing pulp therapy in children to be quite stressful \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The discrepancy in stress levels during endodontic procedures between Polish and English division\u0026rsquo;s students may be partially explained by the lower overall stress levels of foreign students or may be related to the fact that, due to the language barrier, these students receive more support from supervisors and assistance in managing children's behaviour during difficult endodontic procedures. This hypothesis may be supported by the observation that international students experience more stress than Polish students during simple procedures such as impregnation or fluoride application, when much less assistance is provided by the senior dentist. Caries removal in the mandible seems to be less stressful for both national and international responders of the present survey. Also, Farokh-Gisour and Hatamvand who examined dental stress level during performing paediatric procedures by dental students and dentists in Iran observed that preparation of the cavity for mandibular teeth is less stressful, and it was suggested to be due to the direct vision and easy access \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePaediatric dentistry is a demanding specialty that presents numerous stressors which encompass, procedural complexity, some differences between treatment methods in adolescent patients and in adults, behavioural management of anxious children, as well as other factors like parental expectations and the pursuit of excellence in treatment. Due to these challenges, students infrequently opt for specialization in this area of dentistry \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Our study confirmed that paediatric dentistry is assessed as a difficult specialty by the majority of both national and international students. Unfortunately only, 30% of international and 22.66% of Polish students consider working in the field of paediatric dentistry after graduating. Also, the study of Alazmah et al. showed that only a third of 5\u003csup\u003eth\u0026minus;\u003c/sup\u003e year Indian students want to pursue paediatric dentistry as a specialty \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Data from the surveys on US senior students showed even lower interest in this specialty. Immediate postgraduation plans to choose paediatric dentistry specialty have 6.1% of female students and 1.5% of male students, and regarding personal quality of life, only 5% of respondents believed that paediatric dentistry offers the best future. Additionally, just 3% thought this specialty provides the best salary prospects \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe majority of Polish students and those studying dentistry in English experienced moderate to high stress during clinical practice in paediatric dentistry, which, in their opinion, hurt the quality of their clinical performance. Students with higher PS levels feel more stress when performing dental procedures on children. Understanding the nature of stress related to clinical training among dental students, particularly those facing language-related challenges, is crucial for developing support systems that can help mitigate the detrimental effects of stress on their well-being and increase students\u0026rsquo; motivation and interest in pursuing a future practice in paediatric dentistry.\u003c/p\u003e\n\u003ch3\u003eSTUDY LIMITATION\u003c/h3\u003e\n\u003cp\u003eThe result was obtained from a single-center study, so the findings might not necessarily be representative of the entire senior undergraduate dental student population in Poland. The other concern was the small number of participants mainly due to the low response rate of Polish division students. Even though the response rate was much higher among international students, there were only 50 students (25 from 4th and 5th year) in the academic year 2022/2023. Beside non-response bias, a potential limitation is the use a bespoke paediatric dentistry stress questionary which can be bias inherent, but there are no established psychological questionnaires to asses stressors related to paediatric dentistry training. Nevertheless the result of this survey are in line with other research on stress perceived in undergraduate students during performing paediatric dental procedures. This study does not provide data on changes in stress levels over time. However, the implication derived from the present study may be important for university faculty, as they might use the results to improve study conditions and lessen students\u0026rsquo; stress related to clinical practice. In addition, this study compared overall perceived and clinical-related stress within the same cohort of dental students, which is rare in the literature.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAB-Z and JD designed the study, collected and analyzed the data, did the literature search, and wrote the draft of the paper. Both authors reviewed the manuscript.equal co-first authorship\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank senior dental students at the Medical University of Lodz who gave their time to participate in the survey, and Professor Joanna Szczepańska (the Head of the Department of Pediatric Dentistry MUL) for her advice and support.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDATA AVAILABILITY STATEMENTDetailed survey data are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLazarus, R. S. \u0026amp; Folkman, S. \u003cem\u003eStress, appraisal, and coping\u003c/em\u003e (Springer publishing company, 1984).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLazarus, R. S. \u0026amp; Folkman, S. 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Educ.\u003c/em\u003e \u003cb\u003e76\u003c/b\u003e (5), 562\u0026ndash;573 (2012).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"perceived stress, paediatric dentistry, clinical training, dental students","lastPublishedDoi":"10.21203/rs.3.rs-6238639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6238639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eProviding dental treatment for children during clinical training appears challenging for undergraduate students. Various factors, including overall perceived stress (PS) and studying overseas, may affect the way students interpret stressful situations. To gain deeper insights into these issues, an anonymous online questionnaire, consisting of a 5-point scale of stress related to paediatric dentistry training, questions regarding its sources, and the Perceived Stress Scale (PSS-14), was sent via e-mail to 4th- and 5th-year students. A total of 115 students (40 out of 50 enrolled in the English-taught dentistry program and 75 out of 248 Polish) completed the survey.\u003c/p\u003e\u003cp\u003ePolish students showed a statistically higher mean PSS-14 score compared to their foreign counterparts (34.106 vs. 27.575, p\u0026thinsp;=\u0026thinsp;0.000). The mean rating of stress linked to clinical training did not differ significantly between Polish and international students (2.95 vs. 3.23), and for both groups, it correlated with PS level. Respondents identified endodontic treatment and local anaesthesia as the most stress-inducing. Polish students ranked the child's attitude as the top stressor, followed by the supervisor\u0026rsquo;s attitude, whereas international students ranked them inversely. Only 30% of international and 22.6% of Polish students expressed interest in choosing it after graduation.\u003c/p\u003e\u003cp\u003eSupervisors should be aware of stressors inherent to clinical training and differences in stress perception between overseas and native students to mitigate the effects of stress and enhance students\u0026rsquo; motivation for future paediatric dentistry practice.\u003c/p\u003e","manuscriptTitle":"Exploring stressors in paediatric dentistry clinical training among Polish and International dental students at the Medical University of Lodz","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 05:57:52","doi":"10.21203/rs.3.rs-6238639/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T07:41:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-02T12:10:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T22:20:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140770901309537485840434931142132059636","date":"2025-07-27T12:49:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332379925988791276313593544116393637258","date":"2025-07-16T22:55:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-16T11:47:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T04:36:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-08T07:52:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-03T12:38:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-16T20:01:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38393315-47b4-4930-86f8-da3989a2c373","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":51655613,"name":"Biological sciences/Psychology"},{"id":51655614,"name":"Health sciences/Health care"},{"id":51655615,"name":"Health sciences/Health occupations"},{"id":51655616,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-06T14:55:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 05:57:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6238639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6238639","identity":"rs-6238639","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}