PHYSIOLOGIC CHANGES IN ORTHODONTISTS IN RESPONSE TO SPECIFIC ORTHODONTIC PROCEDURES

By: Joana N. Forsea, D.D.S.
NYU College of Dentistry
P.G. Orthodontics Research 1997

ABSTRACT

The focus of this study is to assess if specific orthodontic procedures today are stress inducing to the orthodontic practitioner. Both perceived anxiety and their physiologic responses during certain orthodontic procedures are used to indicate the "stress" response of the body during specific procedures. The literature states that the autonomic nervous system stimulates respiration, heart rate and blood pressure during stressful procedures. Therefore, this study used several questionnaires and measurements of the above mentioned vital signs, to detect stress inducing orthodontic procedures ("orthodontic stressors").

The null hypothesis stated that there was no difference in heart rate (HR), blood pressure (B/p), and oxygenation level (SpO2) during different orthodontic procedures. This study rejected the null hypothesis and accepted the alternative hypothesis that there were psychologic and physiologic differences during specific orthodontic procedures (a physiologic stress response, a.k.a. PSR).

The specific procedures studied were alginate impression taking, insertion of removable appliances, banding, and bonding. There were a total of thirty procedures performed 8 alginate impression taking, 7 banding, 7 insertion of removable appliances, and 8 bonding. The questionnaires showed that most subjects perceived banding and bonding to be anxiety inducing procedures. Subjects did not perceive alginate impression taking as anxiety inducing. During alginate impression taking and banding the vital signs indicated a PSR. The procedures, which did not appear to produce a PSR, were insertion of a removable appliance and bonding. In short, there are certain orthodontic procedures that cause a PSR while others do not.

LITERATURE REVIEW

Assessing levels of occupational stress in medicine and dentistry has been a subject of much concern throughout the last half of the century ⁽¹⁵⁾. Research exploring degrees of stress and its precipitating causes have been already conducted in general and family dentistry. This research suggested that occupational stress in dentistry is greater than in many other types of work. There is no research on occupational stress related to orthodontics. The focus of this paper is on occupational stressors associated with the practice of orthodontics.

The reasons for doing this study are two fold; first, there is no research on stress affiliated with the practice of orthodontics; and second, due to the actions of the third party payers, increasingly large number of patients are seen in current orthodontic practices that solicit more work by the orthodontist. This study specifically addresses orthodontic procedures performed by the orthodontist, and how these procedures affect the operator in terms of stress induction.

There may be many factors that lead to excessive stress in the dental profession ⁽⁹⁾. Among these factors are organization of the office, time constraints, economic/financial pressures, business management designs, working with anxious patients, inflicting pain, dealing with third party payment plans, interpersonal relations with co-workers, and/or overbooking ^(6,14). Specific operational factors generally have not been studied. This study is focused on specific orthodontic procedures and determining if they are job stressors when performed.

Stress has been defined in many ways; for the purpose of this study it will be used in the psychological sense as a factor that induces bodily or mental tension as a reaction to how a person deals with a challenge. A response to stress from a stimulus (such as physical, emotional, internal or external) tends to disturb the organism's homeostasis. The immediate effects of the human stress response are an increase in cardiac output, an increase in stroke volume and systolic blood pressure, an increase in blood flow to skeletal muscles, a decrease in blood flow to the skin, and an increase in blood glucose which are mostly the results of epinephrine (Epi) release into the general circulation ⁽²⁶⁾ (see figure I). Once Epi is released into the general circulation (after cortisol stimulates the change of Norepinephrine to Epinephrine), the following specific events occur:

1. increase in blood pressure
2. increase in blood glucose concentration
3. increase in cellular metabolic rate
4. increase in muscle strength
5. increase in muscle glycogenolysis
6. increase in mental activity
7. increase in muscle blood flow, and
8. an increase in rate of blood coagulation.

Troxler also says that chronic signs of stress are mainly due to cortisol, which can affect the carbohydrate, lipid and protein metabolisms, leading to an increased risk of disease ⁽²⁶⁾ (see figure II). The chronic release of cortisol can lead to stress related diseases, such as coronary heart disease, peptic ulcer, etc. These diseases are not caused by stress directly, it has been shown that chronic exposure to physical or mental stressors will increase one's susceptibility ⁽¹⁷⁾.

What constitutes a stressor? In recent years, there has been increase in information regarding the general effects of stress on the human mind and psyche. Society has a heightened awareness of what stressors are and how they affect us ⁽³⁾. The Dental Clinics of North America published in 1986 is devoted to the topic of dental stress. Understanding dental stress should improve the dentist's physical and mental health and, thereby, improve dental office efficiency and productivity. Stressors are the stimuli that elicit the physiologic responses. There are many stressors associated with job/life stress. Many researchers have speculated on the possible sources of stress in dentistry (known as occupational stress). No research has yet been related specifically to orthodontics.

In the past, occupational stress has focused primarily on the impact of work related stress experiences on physical and mental health. Recently, due to the tremendous changes in the delivery of medical and dental treatment, research has begun to examine relationships between stress encountered in the work place and performance effectiveness as well as the different sources of stress. Research has looked at the potential stressors, and also the identification of specific occupational stressors ⁽¹⁶⁾.

Practitioners should have an understanding about the nature of dental office stressors and the personal dangers they represent to their emotional and physical integrity. Recognition of a stressor may lead to the primary cause, that could be easily changed or modified. Several physiologic parameters of stress have been used to study interventions of stress management or certain clinical situations ⁽¹⁵⁾. Heart rate, systolic blood pressure, diastolic blood pressure, serum Epi, and serum Norepi have all been studied to measure levels of stress ⁽¹⁵⁾. Within a given occupation, stress can vary substantially by factors such as age, gender, perception of the stressor, etc. ⁽²⁰⁾. Also, stress is a perceptual phenomenon, since perception plays an important role in identifying and responding to stressors. Therefore, people who report being under stress do not necessarily display the same reactions. Measuring one's reactions alone does not necessarily ensure that a person is under a given level of perceived stress ⁽⁹⁾. Mallinger states that our personality interacts with our perception of the stressor and our reaction to it ⁽¹⁶⁾. Physical status, such as diet and exercise, may modify the effects of the traditionally proposed outcomes of stressors such as increased blood pressure, etc. An aggregate measure is insensitive to such variation ⁽²⁰⁾. This pilot study collects physical and psychological responses so that their sum gives a good indication of a true stress response to a stressor (to be discussed more in the methods and materials section).

This study measures heart rate (pulse), blood pressure, and non-invasive blood oxygenation levels as physiologic reactions to stressors. It has a four-point questionnaire to measure the cognitive reactions to stressors (Questionnaires I, II, II, & IV).

In the 1995 JCO Orthodontic Practice Study Part I, Gottlieb et. al. notes that there is an increase in the third party payers. There is also a large increase in acceptors of assigned benefits (~74.2%) (Gottlieb et. al., 1995 I). Management of care, leads to an increase in number of patient load and an increase use of some practice management methods, such as delegation of authority ⁽⁷⁾. When procedures are delegated routinely it has been documented that there are more case starts, and more patients can be seen daily. In the 1995 JCO Orthodontic Practice Study Part II, Gottlieb et. al. found that the highest net income practices were more likely to delegate procedures. The following procedures were among the most frequently delegated procedures by practitioners:

1. bonding of brackets
2. adjusting of archwires
3. insertion of bands
4. insertion of removable appliances
5. removal of bands and bonds
6. alginate impression taking

Although the first two have declined slightly in amount of delegation since 1993, the others have increased significantly. Following these conclusions of Orthodontic Practice Studies one asks, " Why are these procedures the most common clinical delegations?" Could it be that subconsciously these are not only time consuming for the orthodontist, but also very stress producing procedures and therefore the orthodontist prefers to delegate these procedures? If they are stressors, then are we over stressing our auxiliaries by delegating these procedures to them?

Research shows that individuals tend to experience more stress if, among other things, they possess a job that fails to use their skills properly, has work overload, and has an environment with excessive physical stressors being present ⁽²⁶⁾. This study will begin to determine if some of our orthodontic procedures are in fact physical stressors. At least 19 major operational (physical) stressors have been identified in the general dentistry field, none have been studied in the orthodontic specialty ⁽¹²⁾. Are we conveniently going on the assumption that orthodontics does not involve physical stressors? Is this because so many of our orthodontic procedures are delegated to our auxiliaries vs. in general dentistry? This study will test four basic orthodontic procedures which Gottlieb et. al. has found to be some of the more commonly delegated procedures.

Stress in the dental working environment is a topic of great importance to everyone associated with dentistry - dentists, staff members and patients. The effective reduction of stress in the dental environment has emotional, health and financial implications for everyone. Learning about our stressors and how to manage them is a necessary skill for all of us who must cope with this rapidly changing and potentially stressful world. If we as physicians/dentists/orthodontists are going to perform to the best of our capabilities, we need to reduce the level of perceived and determined stress felt during patient care ⁽¹⁵⁾. This will increase performance efficiency and possibly increase patient satisfaction.

Figure II, William H. Hendrix, Ph.D., The Dental Stress Model:

CONSENT FORM

ORTHODONTIC RESEARCH : IS STRESS A CONCERN FOR THE ORTHODONTIST?

I,------------------------------------ understand I will be partaking in a P.G. Orthodontic research project. As a subject, I allow Dr. Joana Forsea and/or Dagmara Sperling to measure Heart Rate, Blood Pressure and Blood Oxygen in an non-invasive manner while I am performing the following procedures: (1) Alginate Impression Taking (2) Insertion of Bands (3) Insertion of Removable Appliance (4) Bonding

I also agree to answer the questions asked before, during and after the aforementioned procedures.

METHODS AND MATERIALS

This study measured specific vital signs of subjects/participants while performing certain orthodontic procedures. The subjects/participants in the study were not randomly selected, yet were representative of the average orthodontic resident at least 6 (six) months into the residency program. The subjects participated of their own free will and consented to allow vital signs monitoring during four specific orthodontic procedures:

1. alginate impression taking (alginate)
2. insertion of bands
3. insertion of removable appliances (removable)
4. direct bonding.

The vital signs monitored were the heart rate (HR), blood pressure (B/p), and oxygen levels in the blood (SpO₂). They were measured with the Propaq Encore Monitor that was supplied by Protocol Systems Inc. specifically for this study. This monitor works on any patient, any age, in any location, at any time, according to the Propaq user guide. This is a flexible monitoring system that, reportedly, is the easiest portable monitor to use on ambulatory subjects. It is battery operated, and the blood pressure (NIBP) measurements are optimized for high artifact and patient motion with a Hewlett-Packard B/p cuff. Nellcor oxygen transducers are used to measure the non-invasive SpO2. Measurements were made with the same Propaq Encore monitor for each resident. The method employed was a combination of several methods used in prior similar studies. An extract from the Hamilton Anxiety Scale in combination with an analogue line was used to set up the four point questionnaires. The initial questionnaire, handed out one week before any procedures were measured, is set up along the lines of the Stress Evaluation Survey by Hendrix (Questionnaire I, a.k.a. QI). The second, third, and fourth questionnaires (immediately before, during, and after the performance of the procedure respectively) consists of closed ended questions which were intended to indicate the conscious level of stress/anxiety experienced by the subject/participant. These questionnaires (Q II, III, & IV) were asked at the same precise moment for each procedure. The method used was as follows: the initial questionnaire (QI) was given to the resident about four days prior to performing any of the procedures to be measured the procedures were then performed and this is how the physiologic responses were monitored.

Alginate Impression Taking:

• a. The chair and armamentarium was set up independently of the presence or absence of the patient.
• b. After the patient was seated, the resident was seated in his/her chair and after a two minute resting period, initial vital signs were recorded with the blood pressure cuff on the working arm of the resident. The monitor was positioned behind the resident so the resident could not readily see the monitor screen. This measurement served as the baseline measurement for this resident and, therefore, functioned as the control for this resident for each procedure performed.
• c. After the measurements were made (the B/p cuff was deflated, and remained on the subjects arm) questionnaire II was asked of the resident.
• d. The procedure was started.
• e. After the insertion of the upper tray, but before the alginate gels, a second vital signs measurement is made. The SpO2 monitor was placed on the little finger of the non-working hand of the resident.
• f. After the cuff deflated, questionnaire III was asked of the resident.
• g. The remainder of the procedure was performed.
• h. At the end of the procedure, final vital signs measurements were recorded.
• i. After the cuff deflates, questionnaire IV was posed to the resident then the cuff was removed.

Banding: All of the steps were the same as a-d above. E & f were the only steps that were different. After the fitting of the right mandibular molar, but before its cementation, a second vital signs measurement was made. After the cuff deflates, questionnaire III was asked of the resident. Following steps e & f, g through i were the same as above.

Direct Bonding: All the steps were the same except for e. During direct bonding the vital signs measurement was made after positioning of the right maxillary second premolar for right handed residents, or the contralateral one for left handed residents. This tooth was chosen as it usually presents the operator with the greatest access problems.

Insertion of Removable Appliances: All the steps a-g were the same as above except e was done after the initial try in of the removable appliance but before any adjustments were made to the appliance.

The moment in time that each measurement was made was selected on the assumption that prior to, during, and after the procedure there will be a difference in the vital signs. In the discussion part of this paper what the differences in the measurements indicate will be addressed. The selected times of the measurements during the procedures were thought to be the most anxiety producing moment of the specific procedure.

RESULTS

This study was a prospective study. All the procedures were performed, and the data was collected, and partitioned in two sections; in the first section, the questionnaires were analyzed; in the second, the vital signs. A spread-sheet was made that encompassed the answers to all the questionnaires and recordings of the vital signs (VS). There were thirty procedures performed in all: eight (8) were alginate impression taking, seven (7) were banding, seven (7) were insertion of removable appliances, and eight (8) were bonding.

QUESTIONNAIRE RESULTS Cross tabs were run on the questionnaires and chi-squared analyzed for statistical significance. The results of some of the questions asked had a statistical significance of at least P<.05 to P<.01. Some did not have statistical significance yet showed a trend or direction.

There were 21 respondents to QI. Questionnaire I was the one given to the subjects about a week prior to the performance of any procedures (see Questionnaire I). Ranking the four procedures studied, in order of least to most difficult, subjects thought the least difficult to perform (prior to the procedure being performed) would be alginate impression taking. They stated that insertion of a removable appliance would be moderately difficult.

While banding, they felt would be difficult and bonding definitely the most difficult. However, no matter how a procedure was ranked, most participants indicated a tendency to call all the procedures easy. They felt that, overall, the orthodontic procedures selected were easy to moderately difficult, with a few who felt that the procedures fell outside the two extremes. Banding was the most controversial, because the range of answers were from easy to difficult spread evenly. Bonding was thought to be most difficult, while alg. and rem. were considered very easy to easy respectively. When asked, "Irrespective of the degree of difficulty, which procedure produces the most anxiety to you?" The answers were generally unanimous on banding (48%) and bonding (38%) in that order.

Results show that the level of competence that a practitioner should have in order to perform each procedure was biased towards an above average level needed to perform all four procedures. Prior to performing the procedures, the subjects felt that in order to perform alginate impression taking and banding, a practitioner needed to be most competent. However, they felt that to insert removable appliance and to bond an above average level of competence would suffice. Questionnaires II, III, and IV indicated that anxiety perceived by the subject prior to the procedure being performed, the procedure which would most likely be delegated, and the competency level of the subject judged after the procedure was performed, were all significant.

Prior to performing the procedures of alginate impression taking and insertion of removable appliances, subjects generally did not perceive any anxiety. However, prior to banding and, especially, bonding subjects perceived mild to moderate amounts of anxiety. The level of anxiety declined during the performance of the procedure.

After performing the procedure, the subject was asked if s/he would likely delegate the procedure just performed to an auxiliary. The results were significant to P< .05. Eighty-seven point five (87.5%) of those who performed the alginate impressions would delegate that procedure, while 57% would likely delegate insertion of a removable appliance, and 62.5% would not delegate bonding. Banding was unclear in this category because the results were 43% would, 43% would not, and 14% were unsure.

Before and then after these procedures, subjects were asked what level of competency they felt a practitioner needed to perform these four procedures to a minimum quality level. After the performing of the procedures, the subjects who performed banding and bonding answered that "Yes" a high degree of competence was required. Most rated themselves as having performed these procedures average to slightly above average. Those who performed insertion of removable appliances, all said that a high degree of competence was not required. They also felt that their performances were generally above average to most competent. Finally, of those who performed alginate impressions, 50% felt a high degree of competence was required while 50% felt it was not.

The participants felt their performances of alginate impression taking were generally above average to one participant who felt s/he was excellent. These results were compared with their answers of competency from before the procedure was performed. The bonding procedure was the only one consistent with what the participants believed prior to performing the procedure. Alginate impression taking, banding, and insertion of removable appliances were somewhat inconsistent with the initial results. After performing the procedures, subjects felt that one needed to be very competent to perform alginate impressions and insertion of removable appliances and most competent to perform banding.

VITAL SIGNS RESULTS All of the vital signs measured were divided into two categories; first, by procedure, and second, by vital signs. Then a repeated ANOVA (analysis of variance) was performed.

The first category was descriptive statistics that involved the systolic and diastolic blood pressures. The measurements were taken before, during, and after the procedure and compared. At least 2mmHg differential between the readings was set as the minimum for them to be called significant changes. Alginate impression taking showed that an overwhelming 62.5% of the participants had B/P increase during the procedure. During banding, 43% of those measured showed an increase in B/P. During insertion of removable appliances 71.5% of the subjects' B/P decreased. Bonding showed that 37.5% of the subjects had an increase in B/P while 25% had a decrease from the baseline.

The second analysis was a repeated means analysis of variance with each procedure as an independent variable. This analysis arranged each procedure within the four measurements and compared the procedure before, during, and after for that measurement (see charts I-IV).

The systolic B/P had significance of P<.01 and depicted Alginate impression taking and banding as having an increase in B/P during the procedure. Insertion of removable appliances showed a decrease in blood pressure during the procedure. Bonding showed a very slight increase in B/P during the procedure (see chart I).

The diastolic B/P showed a general tendency to increase during all procedures except insertion of removable appliances where it decreased (P<.01). Although the diastolic measurements were significant, they were more easily influenced by systemic interferences. Therefore, the diastolic measurements were used as support of the systolic results (see chart II).

The heart rate followed the trend set by the systolic and diastolic B/P. Heart rate increased during alginate impression taking, banding, and insertion of removable appliances. During bonding the heart rate decreased. It is speculated that for insertion of removable appliances the HR increased as a compensatory mechanism secondary to standing during the procedure to compensate for a greater need to pump blood against gravity (see chart III).

The pulse oxymeter measured the level of oxygen in blood. The range between each measurement was very small (SpO2 97-99%). The results indicate that for alg., banding and bonding there was a decrease in blood oxygen. A depletion in blood oxygen may indicate an increase in respiratory rate. When a person hyperventilates and expulses O2, SpO₂ may decrease. However, a decrease in blood oxygen could also occur with a decrease in respiratory pattern due to increased focus and decreased bodily movement. The tendency was a decrease in SpO₂ by the end of each procedure. The amount of change in SpO₂ was quite minimal and therefore less contributory to indicating a PSR, but functioned to support the interpretations of a PSR based on the B/P and HR(see chart IV).

In short, the results indicate that some procedures, when performed, do increase B/P and HR and affect SpO₂. Alginate impression taking and banding indicated a PSR was initiated. The insertion of a removable appliance did not stimulate a PSR and bonding was unclear. The interpretation of the stress response and its correlation with the answers to the questionnaires will be discussed in detail in the discussions portion of this paper. There are many factors that influence the PSR, such as age, perception, personality type, gender, etc. ^(20,23). Here are some variables that were taken into consideration during this study:

VARIABLES THAT INFLUENCED THE PSR

• Standing-VS-sitting during the procedure.
• Required level of competence to perform the procedure (not the level of competence of the resident per se, but what level of competence the resident felt a practitioner needed in order to perform the procedure).
• Operator error.
• Level of assessed outcome (standard of care), because a subject desiring an above average outcome could have been more anxious during the procedure.
• The health of the subject.
• If the procedure being performed is a pain inducing procedure to the patient.

The questions asked of the participants showed a correlation between certain issues and the PSR. For example, the mean level of confidence in each subject prior to performing the procedure was determined to be confident to very confident. Therefore, the subjects' confidence levels became insignificant towards influencing the subjects' physiologic stress response. All of the subjects had neutral to very fond feelings about their patients; none felt any animosity towards them. During the procedures the subjects were asked if the procedure was going easier, as, or harder than anticipated. All the procedures were deemed going as anticipated or easier than anticipated. The responses to these questionnaires suggested that these issues were noncontributory to the PSR that were measured.

VARIABLES NOT SIGNIFICANT TO THE PSR IN OUR STUDY (Because the significance level of our results was P< .01-.05, these variables were thought to be insignificant for this study.)

• Interference of the B/P cuff (VS measurements were not intrusive components).
• Perceived level of anxiety of the subject.
• Perceived difficulty level of the procedure.
• Residents performing the procedures, and not seasoned orthodontists.
  Schwartz did a study where he looked at stress and performance of the internal medicine intern. The study showed that the contributions of both experience and environmental stressors determined the extent of reported and detected distress. The study also concluded that the average levels of stress decreased when the internal medicine resident advanced in levels of training. It was concluded that because the first year residents lacked sleep and were overworked they had higher stress levels ⁽²⁴⁾. These conclusions cannot be directly applied to the average first and second year orthodontic residents. This variable becomes insignificant because all of the participants were residents. However, this variable should be looked at in future studies.
• The thickness of the sleeve worn by the subject. This was insignificant because it was consistent for all measurement before, during, and after for each subject.
• A different patient was in the chair for each procedure studied. However, it did not influence the findings because, as mentioned above, it was determined that all residents studied had good relationships with their patients. No animosity existed.
• Computer error was the same for each procedure because the same calibrated monitor was used for all recordings.
• Asking of the questionnaires during the procedures was not intrusive.
• Participant cooperation was minimally required because the resident was told to perform the procedure as s/he normally would have.

VARIABLES THAT SHOULD BE ADDRESSED IN FUTURE STUDIES

• Time constraints:
• One time of day may be more stressful than another.
• Time allowed per procedure.
• Gender:
• Patient's gender.
• Gender of subject ^(11,13). ·
• Psycho-social background of the subject. ·
• Patient management skills. ·
• Personality type of the subject. ·
• Age of the subject.

DISCUSSION

Interpreting physiologic responses during specific orthodontic procedures helped identify the orthodontic procedures that were considered stress inducing. There are many different responses to stressors, a startling response vs. an orienting response, etc. Some stress is considered eustress, in which case this stress is desirable, such as exercise.

Several studies have shown that serum epinephrine (E) changes appear to be reliable markers of stress secondary to mental stressors. Serum norepinephrine (NE) changes reflect stress secondary to physical challenges. As Troxler's Human Stress Response indicates, NE becomes E by when cortisol stimulates it. Classically, serum cortisol changes have been used to best indicate a stress response to a physical and/or mental stressor. More recently research has shown that B/P, HR and even respiratory rate has a strong correlation to changes in serum NE and can predict a stress response.

The following were the designated response indicators that this study used:

A significant increase existed if 2mmHg or more changes from the initial B/P reading. For HR, + 1 beat was significant, while for SpO2 changes of + 1% were considered significant.

The psychological interpretation of stress/anxiety of the subjects undergoing each procedure was determined by a series of questionnaires. The procedures selected were chosen based on: 1) the procedures that Gottlieb et.al.⁽⁸⁾ found were the most delegated by orthodontists nation wide, 2) Insertion of a removable appliance was selected because it was thought to be the least anxiety producing procedure and therefore it would act as a control vis-a-vis the other three procedures.

The PSR inducing procedures were alginate impression taking and banding. The results also show insertion of removable appliances as not stress inducing, with B/P decreasing and SpO₂ normal. Heart rate for this procedure was ironically increased. Beek states that, in healthy patients with normal blood volume, blood viscosity, and elasticity of blood vessel walls, there are two variables which influence B/P: 1) cardiac output (stroke volume + HR) and 2) total peripheral vascular resistance(1). Therefore, if B/P is constant or decreases and HR increases it is usually due to a compensatory reduction in stroke volume (and/or peripheral vascular resistance). Reduction in stroke volume occurs when one is standing as opposed to sitting, because blood return is affected by gravity.

It is unclear whether bonding produces a PSR. While bonding, the B/P increases yet HR decreases. This decrease in HR makes it difficult to say if a PSR exists during the procedure. This decrease in HR could also be accounted for by an increase in stroke volume that occurs as a reaction to the subject sitting down while working. The SpO₂ decreases during the procedure indicating one of two things, either a PSR was occurring or a decrease in respiratory rate exists because the subject was sitting and not standing during the procedure. Bonding should be looked at again in a future study that has a larger sample size.

The answers to the questionnaires for each procedure performed allow for some conclusions to be drawn.

ALGINATE IMPRESSION TAKING

After performing the procedures, this procedure was found to require the least amount of competence to perform and the least difficult procedure of the four studied. This was the second to the least anxiety producing procedure following insertion of removable appliances. It was also considered the procedure to most likely be delegated to an auxiliary. For the majority of the subjects their B/p increased, their HR increased and their SpO₂ decreased. These results indicate a PSR occurred during this procedure. The subjects said they felt none to mild anxiety during the procedure and that the procedure was going as anticipated or easier.

If the subjects did not recognize this procedure as stress inducing, why did a PSR occur? One possible reason could be because the procedure was performed standing up, but so was insertion of removable appliances and that procedure did not produce a PSR. Another reason could be because the procedure produced discomfort to the patient, and this discomfort was felt by the doctor, so the anxiety level increased and thereby stimulating a PSR. Finally, the PSR could be caused by the anticipation of the unknown the doctor could be feeling. The patient could gag at any moment and this ambiguity could be a great stressor, and thereby produce a PSR.

BANDING

Banding was considered the second to the most difficult procedure performed after bonding. It was found as one of the most anxiety producing procedures, along with bonding. The majority of participants felt very confident to perform this procedure. It was perceived as a procedure requiring a high degree of competence to perform. As the procedure began, the subjects felt mild to moderate levels of anxiety, although the procedures were proceeding as anticipated or easier than anticipated. After the procedure was performed, the subjects felt they performed average to above average quality work. Finally, although the results may be contradictory, 43% of the subjects felt they would delegate this procedure. The results show an increase in B/P, HR, and a decrease in SpO₂, a definitive PSR.

INSERTION OF REMOVABLE APPLIANCE

Insertion of a removable appliance was found to be least difficult to perform. It was the least anxiety producing procedure. Prior to performing this procedure, the subjects felt that the practitioner needed to be highly skilled and very competent to perform this procedure. After the procedure was performed, the subjects changed their opinions and felt that a high degree of competence was not needed. Residents felt very confident of their ability to perform this procedure well. It generally proceeded as anticipated or easier than anticipated. Eighty-five percent (85%) ranked their performance of the procedure as above average, and 57% would most likely delegate this procedure.

During this procedure there was a decrease in B/P, normal SpO₂, and slight increase in HR. There was no indication of a PSR. The probable reason for the increase in HR was a compensatory reaction to the practitioner standing rather than sitting during the procedure, as mentioned above.

BONDING

This procedure was ranked as the most difficult to be performed. It was thought to require a high to very high degree of competence. The confidence level of the residents was average prior to performing the procedure. About 50% felt mild anxiety prior to performing the procedure. During the procedure about 25% felt mild anxiety, and 12% felt the procedure was going harder than anticipated. After the procedure was over, the majority of the residents felt their performance of the procedure was average. Even though the subjects felt this was about the procedure, 87.5% felt likely to delegate this procedure if allowed by their state dental practice acts.

According to the initial questionnaire (QI), Banding and Bonding were considered the most anxiety producing procedures of the ones studied. While Banding produced a PSR, Bonding is unclear. For Bonding the results show a slight increase or leveling of the B/P, with a significant decrease in HR and SpO2 during bonding. The decrease in HR is most likely due to a physiologic compensation of the body in a sitting, focused, non-mobile position. The decrease in SpO2 is thought to be because of an increase in concentration and focus, and lack of excessive bodily movements leading to decreased respiratory rate and decreased oxygen intake. Finally, 37.5% of participant's B/P increased and 37.5% remained normal. If a larger sample size would have existed, a more clearly defined conclusion could be drawn. For now, the conclusion drawn was a physiologic reaction that indicated a focus of attention.

CORRELATIONS

There are certain patterns and correlations that can be drawn from the results(see Tables I & II):

1. Perceived anxiety and the PSR. Contrary to what Beek found ⁽¹⁾, there is no correlation between perceived anxiety of a subject and that subject's PSR during the studied procedures. Subjects are unaware that physiologic responses may indicate stress, even though they do not perceive the procedure as stressful (e.g. Alginate impression taking). On the other hand, participants may perceive stress although their physiologic response may not indicate that their body is reacting to a stressor (e.g. Bonding).
2. Competence level and PSR. The correlation is very straightforward. A procedure that requires a high degree of competence to perform generally produces a PSR (e.g. Banding and Alginate and possibly Bonding).
3. Perceived level of difficulty and PSR. There is no correlation between how difficult a procedure is thought to be and the PSR.
4. Perceived level of difficulty and delegation of duties. There is a slight correlation between how difficult the procedure is thought to be and the likelihood of its delegation to an auxiliary. The more difficult the procedure, and the more time consuming it is, the greater the likelihood of its delegation (e.g. Alg., banding, etc.).
5. Reasons for a PSR during Banding and Alginate impression taking.
   a. Banding- It can be pain producing to the patient. - It is a more invasive procedure. - There is an immediate negative sequela to this procedure if done incorrectly (e.g. Bleeding, bite opening,cheek biting, discomfort, fracture of tooth or enamel of tooth, etc.).
   b. Alginate- The doctor is standing. - There is increased discomfort to patient. - The doctor has heightened awareness that patient may gag at any moment.
6. Self-Assessment of Outcome and the PSR. After the performance of the procedure, each resident was asked to assess his or her performance. Most residents rated themselves as average to above average for all procedures. No one felt they performed the procedure poorly or merely adequately. Sixty two and one half percent (62.5%) felt they performed alginate impression taking above average. Of those who performed the banding procedure, 43% said they performed average, 43% felt above average, and only 14.3% felt their performance was exceptional. Eighty six percent (86%) of those who performed insertion of removable appliances felt their performance was above average. Finally, 62.5% of those who did the bonding procedure felt their performance was merely average, and none felt they performed it exceptionally well.

Table I shows that there is slight correlation between the assessed outcome of the procedure and the PSR. The better the assessed outcome, the less chance of a PSR occurring exists. Questions could be raised in future studies such as, "Do outcomes become compromised when performing a procedure that is stress inducing?" As health care evolves to embrace a growing number of patients and adapt to economic pressures, health care professionals also would like to maintain a certain quality of care, that is why this correlation was looked at.

CONCLUSIONS

In summary:

1. Alginate impression taking causes a PSR.
2. Banding causes a PSR.
3. Insertion of a removable appliance DOES NOT cause a PSR.
4. Bonding is UNCLEAR if it causes a PSR or not.

These were the basic results of this study. Several conclusions can be drawn from them:

• The most difficult procedure was Bonding.
• The most anxiety producing procedure was Banding.
• Most felt anxiety before performing Banding and Bonding.
• The most likely procedures to be delegated were Alginate Impression Taking, Banding and Insertion of Removable Appliances. These procedures were thought to be less difficult than Bonding, but that did not exclude the possibility of a PSR to occur.
• Competence level was above average for all procedures. As the required level of competence increases, the chance of that procedure to produce a PSR increases.
• A perceived level of difficulty to perform a procedure or a perceived level of anxiety does not indicate the probability of a procedure to produce a PSR. A PSR could occur even without the resident/subject being aware of it.

Further research in this area would seem warranted. This same study should be done using a larger sample size and including some of the variables that were mentioned above. A coping mechanism could be introduced while performing the procedure, for example, breathing exercises. This study could be expanded to include other procedures and/or test cooperative vs. non-cooperative patients as they relate to the practitioner.

Hendrix states that, ultimately, procedures that stimulate a PSR influences job satisfaction, anxiety levels, commitment level, depression, performance decrease, turnover rate increases, absenteeism and tardiness increase, and there is an increase in physical debilities ^(9,18). If this is true, then are we subconsciously delegating stress inducing procedures, to increase practice size, at the expense of our auxiliaries? Furthermore, in the future outcome studies can be done to determine if stress-inducing procedures, especially those that are delegated, affect the orthodontic standard of care.

BIBLIOGRAPHY

1. Beek FM, Weaver JM. Blood pressure and heart rate responses to anticipated high stress dental treatment. J of Dent Res 1981;60:26-29.

2. Capner M, Caltabiano ML. Factors affecting the progression towards burnout: a comparison of professional and volunteer counselors. Psyc Reports 1993; 73:555-561.

3. Christen AG, Christen JA, Nevin RS. Active cooping strategies: from self-help to psychological counseling. The Dent Clin of N Am, Oct. 1986; 30(4):S67-S78.

4. Cooper CL. Dentists under pressure. A social psychological study. White Collar and Prof Stress 1980; 3-17.

5. Cooper CL, Mallinger M, Kahn RL. Dentistry: what causes it to be a stressful profession? A review of the literature. Int Rev Appl Psyc 1980; 29:307-319.

6. DiMatteo MR, Shugars DA, Hays RD. Occupational stress, life stress and mental health among dentists. J of Occ and Org Psyc June 1993; 66 (2): 153-162.

7. Gottlieb EL, Nelson AH, Vogels DS. Orthodontic practice study, part I. J of Clin Ortho Oct 1995; 29(10):633-642.

8. Gottlieb EL, Nelson AH, Vogels DS. Orthodontic practice study, part II. J of Clin Ortho Nov 1995; 29(11):691-699.

9. Hendrix WH. Dental stress model and assessment questionnaire. The Dent Clin of N Am Oct 1986; 30(4): S1-S10.

10. Heim E. Job stressors and coping in the health profession. Psychotherapy and Psychosomatics 1991; 55(2-4):90-99.

11. Heim E. Stressors in health occupations. Do females have a greater risk? Zeitschrift fur Phsychosomatische Medizin und Psychoanalyse 1992; 38(3): 207-226.

12. Howard JH, Cunningham DA, Rechnitzer PA, et. al. Stress in the job and carrier of a dentist. J of Am Dent Ass 1976; 93: 630-636.

13. Janus CL, Janus SS, Price S, et.al. Residents: the pressure's on the women. J of Am Wom Ass 1983; 38:18-21.

14. Katz CA. Stress factors operating in the dental office work enviornment. The Dent Clin of N Am 1986; 30(4): S29-S36.

15. Levitt MA, Derrick JR. An evaluation of phsyiological parameters of stress in the emergency department May 1991; 9(3): 217-219.

16. Mallinger MA, Brousseau KR, and Cooper CL. Stress and success in dentistry: some personal characteristics of successful dentists. J of Occ Med 1978; 20: 549-553.

17. Mason JW. A review of psychoendocrine research on the pituitary-adrenal cortical system. Psychosom Med 1968; 30: 576-607.

18. Murtomaa H. Work related complaints of dentists and dental assistants. Int Arch Occ Env Health 1982; 50: 231-236.

19. Murtomaa H., Haavio-Mannila E., Kandolin I. Burnout and its causes in Finnish dentists. Com Dent Oral Epid 1990; 18: 208-212.

20. Simpson LA, Grant L. Sources and magnitude of job stress among physicians. J of Behav Med 1991; 14(1): 27-41.

21. Spielberger CD, Reheiser EC. Measuring occupational stress. The Job Stress Survey. Occupational Stress; a handbook. in Series in Health Psychology and Behav Med 1995: 51-69.

22. Stawn CE, Time management practices for the dentist. The Dent Clin of N Am Oct 1986; 30(4): S107-S116.

23. Sutherland VJ, Cooper CL. Identifying distress among general practitioners: predictors of ill-health and job dissatisfaction. Soc Scie Med 1993; 3-7(5): 575-581.

24. Schwartzz AI, Black ER, Goldstein MG. et.al. Levels and causes of stress among residents. J of Med Edu 1987; 62: 744-753.

25. Swogger G Jr., The type A personality: overwork and career burnout. The Dent Cin of N Am Oct 1986; 30(4): S37-S54.

26. Troxler RG. Human stress response and its possible relationship to disease. The Dent Clin of N Am Oct 1986; 30(4): S11-S27.

Dr. Forsea did her undergraduate work at the University of Colorado, in Boulder and attended medical school in Bucharest, Romania. She received her DDS and MS in Orthodontics from NYU and is currently in private practice in the New York City area. She is also a Clinical Assistent Professor with the Department of Growth and Development at NYUCD.