ORIGINAL ARTICLE

Stress and anxiety in orthodontic

residents during the coronavirus disease
2019 pandemic
Edmund Khoo,a,b Sophia G. Saeed,c Hong-Yan Chiu,d Vicky Quach,e Malvin Janal,f and Kelton Stewarta
Indianapolis, Ind, Rochester and New York, NY, and Farmington, Conn

Introduction: The coronavirus disease 2019 pandemic has had far-reaching effects on health care providers
and health professional students; however, little is known about the factors related to stress and anxiety
levels, specifically among orthodontic residents during this time. Methods: A 2-part questionnaire, which
included modified stress and anxiety inventories, was disseminated electronically to U.S. orthodontic
residents between June and July 2020. Descriptive and comparative statistics were used to analyze the data.
Results: Overall, 261 participants responded (56% female), representing a response rate of 26.8%. Significant
gender differences were found in 18 stress items, with female respondents expressing more stress than their
male counterparts. Only 1 stress item (ie, fear of being unable to catch up if behind) varied as a function of
the difference on the basis of respondents’ stage in the program. First-year residents reported more stress in
relation to this than more senior residents. Responses to all anxiety items but 1 item varied by gender, with
females reporting higher scores. Residents in the middle stages of their program responded with higher
anxiety scores with significant differences on 3 anxiety items. Conclusions: Although financial responsibilities
and travel plans were the most stressful and anxiety-inducing items for orthodontic residents during the early
aspect of the coronavirus disease 2019 pandemic, multiple items contributed to their stress and anxiety. In
addition, both gender and stage of progress in a residency program impacted the level of stress and anxiety
reported by respondents. (Am J Orthod Dentofacial Orthop 2022;162:e35-e43)

T
here has been a growing interest in burnout among general population, with an increasing trend over
health care providers and health professional stu- time.13,14 Other health professions soon followed suit
dents in the United States and across the world.1-11 in studying how stress and burnout present among their
Burnout is associated with stress, inefficient work cohorts, including students and residents.10,11,15 Stress
processes, and barriers to achieving meaning in one’s levels among dental students are higher than medical
work.1-4,12 Concerns and studies related to health students16; however, it is challenging to compare dental
care worker burnout originated from the medical residents to medical residents, primarily because of the
specialty. Although physician burnout varies by specialty, scarcity of data relative to dental residents. Depending
the average rate of physician burnout is higher than the on their stage in the curriculum, stress among dental stu-
dents is associated with academic factors, clinical factors,
inconsistent faculty feedback, assigned workload, per-
a
Department of Orthodontics and Oral Facial Genetics, Indiana University School formance pressure, and self-efficacy beliefs.17,18 Levels
of Dentistry, Indianapolis, Ind.
b of anxiety among dental students have also been
Eastman Institute of Oral Health, University of Rochester, Rochester, NY.
c
School of Dental Medicine, University of Connecticut, Farmington, Conn. high.19,20 Within the field of orthodontics, specifically,
d
Department of Orthodontics, College of Dentistry, New York University, New factors impacting the stress and anxiety of residents
York, NY.
e have not been well-studied.
College of Dentistry, New York University, New York, NY.
f
Department of Epidemiology and Health Promotion, College of Dentistry, New In the early months of 2020, the coronavirus disease
York University, New York, NY. 2019 (COVID-19) pandemic created a significant global
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
impact. In the United States, most people experienced
tential Conflicts of Interest, and none were reported.
Address correspondence to: Edmund Khoo, 301 E 22nd St, Apt 9M, New York, NY mandated lockdowns, making them unable to interact
10010; e-mail, [email protected]. with anyone other than those they lived. This isolation
Submitted, October 2021; revised and accepted, April 2022.
worked to increase stress among the general public.21
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved. Primary and secondary education quickly transferred
https://doi.org/10.1016/j.ajodo.2022.04.011

e35
e36 Khoo et al

to online modalities, and those with young children questionnaire specifically stated that participants
had to adapt. As more became known about the were asked to “Participate in a survey to assess your
emerging severe acute respiratory syndrome coronavi- feelings about the impact of the novel coronavirus
rus 2 virus, some essential segments of society reop- that causes COVID-19.” In addition, survey questions
ened, including health care. Personal protective were prefaced with the following statement, “In
equipment (PPE) was in short supply, and during the response to the COVID-19 pandemic, please indicate
first 6 months of the pandemic, dental professionals the degree to which you experience stress from each
were thought to be at very high risk of occupational of the items listed below as part of your orthodontic
exposure22 because of the aerosols generated during education experience.” The questionnaire included de-
treatment. Residents and students were unsure if they mographic data on gender and stage in the program.
would be able to attain the clinical experiences needed Because of the variability in the duration of orthodon-
to complete their training on time or with confidence. tic programs, the stages in the program were classified
Influenced by the university, dental board, and govern- as first year, midway, and final year. Two sets of mea-
mental recommendations, the guidance to the specialty sures were used to assess stress and anxiety.
continued to shift, as did the availability of PPE and The Dental Environmental Stress Questionnaire
the willingness of patients to present for treatment. (DESQ), a validated 38-item instrument,23 was modi-
This required constant adaptation and flexibility. This fied to be more orthodontic-specific. Survey modifica-
multitude of pandemic-associated factors appeared to tions included removing some items and adding 2
magnify the amount of stress and anxiety experienced new items to assess the impact of perceived discrimi-
by dental students and residents, including orthodontic nation on stress. The final modified DESQ used for
residents. Stress, anxiety, and burnout among health this study contained 37 items broken down into 10
care providers are associated with decreased productiv- categories: self-efficacy beliefs, faculty and adminis-
ity, increased errors, and poorer quality of care for pa- tration, workload, patient treatment, clinical training,
tients. However, no studies have sought to elucidate performance pressure, personal relationships, personal
the impact of the COVID-19 pandemic on the levels life, professional life, and discrimination. Residents
of stress and anxiety experienced by orthodontic resi- were asked to assess each item as not stressful,
dents in the United States. slightly stressful, moderately stressful, or very stressful.
Therefore, this study aimed to gauge the factors that Respondents rated the 37 items on a 4-point Likert
impacted the stress and anxiety of North American or- scale (1, not stressful; 2, slightly stressful; 3, moder-
thodontic residents during the early months of the ately stressful; and 4, very stressful). An additional op-
COVID-19 pandemic. tion (0, not pertinent) was given for items that did
not apply to the respondent. The scale was modified
from the original DESQ, which scored the items 0-3
MATERIAL AND METHODS
and did not include a not pertinent response option
Residents enrolled in North American postgraduate (Table I).
orthodontic programs in June 2020 were invited to Anxiety was assessed using a 9-item instrument
participate in this study. An online questionnaire adapted from a published questionnaire24 used to
was constructed using Qualtrics software (Qualtrics, measure self-reported anxiety during the 2009-2010
Provo, Utah); Institutional Review Board approval H1N1 swine flu pandemic. The “swine flu” was
(IRB-FY2020-4497) was obtained from New York Uni- changed to “COVID-19.” Respondents rated each
versity. The questionnaire was distributed via e-mail item on a 4-point Likert scale (1, very little; 2,
to North American orthodontic residents through the somewhat; 3, a lot; and 4, very much). The questions
American Association of Orthodontics Partners in were sequenced randomly to minimize response bias
Research Program. The questionnaire was also posted (Table II).
to the American Association of Orthodontics Residents To compose a summary measure for the stress items
Champion Facebook (Meta Platforms, Inc, Menlo Park, (total stress score), we determined the internal consis-
Calif) page. The questionnaire was administered from tency for the 26 stress items, with at least 200 responses
June 2020 to July 2020, with 2 reminders sent at 4 not including nonpertinent. Cronbach alpha was 0.93,
and 6 weeks. Informed consent was obtained from which is excellent. The summary measure for the anxiety
the respondents; participation was voluntary and scale (total anxiety score) included all items. Cronbach
anonymous. Because there was no data on orthodon- alpha was 0.84, which is good.25
tic residents using a similar survey instrument before The data were analyzed using descriptive statistics.
the COVID-19 pandemic at the study, the Gender differences were evaluated with the Mann-

July 2022  Vol 162  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Khoo et al e37

Table I. DESQ for orthodontic residents Table II. COVID-19 anxiety items
Category Items 1. To what extent are you concerned about COVID-19?
Self-efficacy Lack of confidence to be a successful 2. To what extent do you believe COVID-19 will have lasting impacts
beliefs orthodontic resident on the world?
Lack of confidence in self to be a successful 3. How likely is it that you could become infected with the novel
orthodontist coronavirus that causes COVID-19?
Completing graduation requirements 4. How likely is it that someone you know could become infected
Fear of failing a course or year with the novel coronavirus that causes COVID-19?
Receiving criticism about work 5. How much exposure have you had to information about COVID-
Faculty and Atmosphere created by the faculty 19?
administration 6. If you did become infected with the novel coronavirus that causes
Rules and regulations of the program COVID-19, to what extent are you concerned that you will
Amount of cheating in program become seriously ill?
Expectations of the program and what, in reality, 7. To what extent has the threat of COVID-19 influenced your
it is like decisions to be around people?
Lack of input into the decision-making process 8. To what extent has the threat of COVID-19 influenced your travel
of the program plans?
Inconsistency of feedback on work between 9. To what extent has the threat of COVID-19 influenced your use of
different instructors safety behaviors (eg, hand sanitizer)?
Workload Amount of assigned classwork Note. Adapted from the H1N1 anxiety survey.24
Difficulty of classwork
Lack of time to do assigned work
Lack of time for relaxation
Fear of being unable to catch up if behind RESULTS
Patient treatment Responsibilities of comprehensive patient care
Patients being late or not showing for their A total of 261 responses were received. Based on an
appointments estimated yearly enrollment of 975 orthodontic resi-
Working on patients with dirty mouths dents, the response rate was 26.8%. Most respondents
Clinical training Difficulty in learning clinical procedures
Difficulty in learning precision manual skills
were female (55.9%), and there were a similar number
Performance Examinations and grades of respondents in each stage of the program. Summary
pressure demographics of the sample population, based on
Competition for grades gender and stage of progress, are presented in Table III.
Personal Relationships with members of the opposite Financial responsibilities were rated the most stressful
relationships gender
Martial or relationship adjustment problems
of all factors assessed, with 63.9% (n 5 219) of respon-
Forced postponement of marriage or dents rating it as moderately stressful or very stressful.
engagement Lack of input into the decision-making process of the pro-
Having children at home gram caused stress in 60.6% of the respondents. Several
Necessity to postpone having children other items were ranked as moderately stressful or very
Conflict with a partner over career decisions
Having the dual role of wife/mother or husband/
stressful by the majority of respondents and included re-
father and orthodontic resident sponsibilities of comprehensive care (58.3%), insecurity
Personal life Personal physical health regarding professional future (57.5%), and difficulty
Financial responsibilities learning clinical procedures (57.5%).
Lack of home atmosphere in living quarters There were 7 items that few respondents considered
Professional life Insecurity concerning professional future
Considering entering some other field of work
moderately stressful or very stressful. These include, in
Discrimination The attitude of the school toward female dental ascending order, amount of cheating in the program
students (3.0%), relationships with members of the opposite
Discrimination because of race, class status, gender (3.5%), conflict with a partner over career deci-
ethnicity, or other minority groups sions (6.8%), the attitude of the school toward female
dental students (9.1%), forced postponement of mar-
Whitney U test and program stage differences with the riage or engagement (9.2%), and competition for grades
Kruskal-Wallis test. Total stress and anxiety score differ- (9.2%) (Table IV).
ences were evaluated using a 1-way analysis of variance. A total of 18 items (48.6%) showed statistically sig-
All analyses were completed using IBM SPSS (version 28; nificant differences between genders (Table IV). In all
IBM Corp, Armonk, NY). Statistical significance was set subjects, female respondents reported more stress than
at P \0.05. their male counterparts.

American Journal of Orthodontics and Dentofacial Orthopedics July 2022  Vol 162  Issue 1
e38 Khoo et al

Table III. Summary demographics of the sample population by gender and stage of progress with an overall response
rate
First year (37.9%) Midway (27.2%) Final year (34.9%) Total Overall response rate

Demographics n % n % n % n %
Male 35 35.35 31 43.66 43 47.25 109 26.8
Female 62 62.63 37 52.11 47 51.65 146
Unspecified 2 2.02 3 4.23 1 1.10 6
n 99 71 91 261

Only 1 item (ie, fear of being unable to catch up if the following categories: clinical training, patient treat-
behind) varied as a function of the respondents’ stage ment, faculty and administration, and personal life. This
in the program. First-year residents reported more stress is comparable to existing evidence on the stress levels in
in relation to this item than more senior residents dental students and graduate students.17
(P \0.0001). For individual stress-provoking items, the highest-
Respondents reported 3 items that caused a lot or ranked item was financial responsibilities. In addition to
very much anxiety: (1) To what extent has the threat the well-documented increasing cost of dental education,
of COVID-19 influenced your travel plans? (84.5%); (2) the high unemployment rate, a parallel spike in U.S. infla-
How much exposure have you had to information about tion rates, and the need to switch to online remote
COVID-19? (81.6%); and (3) To what extent has the learning for school-aged kids may have compounded
threat of COVID-19 influenced your use of safety behav- financial strains that orthodontic residents already experi-
iors (eg, hand sanitizer)? (80.6%). The 3 lowest-ranked enced baseline. For financial reasons, many senior prac-
items were (1) If you did become infected with the novel ticing clinicians decided to continue to practice rather
coronavirus that causes COVID-19, to what extent are than retire. Moreover, others were not in a financial posi-
you concerned that you will become seriously ill? tion to hire new associates. These elements likely height-
(20.0%); (2) How likely is it that you could become in- ened orthodontic residents’ stress associated with
fected with the novel coronavirus that causes COVID- finances.
19? (39.2%); and (3) To what extent are you concerned The second highest-ranked stress item was a lack of
about COVID-19? (46.5%) (Table V). input into the decision-making process of the program.
Responses to all items except 1 varied by gender, with This reflects a top-down management approach in
females reporting higher scores (Tables V and VI). which department chairs, program directors, and admin-
There were significant differences on 3 items, with istrative leadership make decisions without input or
residents in the middle stages of their program respond- involvement from their constituents. Style of leadership
ing with higher anxiety scores (Table V). and management are critical to setting the tone for an
Total stress scores were higher in female vs male re- organization, and the top-down approach is now
spondents but did not differ as a function of their stage considered by many to be outdated. Today’s students,
in the program. Total anxiety scores were also higher in residents, and workers expect to be viewed more as part-
females than male respondents and higher in those at ners who have a say in decision-making. The top-down
the beginning or end of the program than those in the approach of many dental institutions, including ortho-
middle (Table VI). dontic programs, may be a generational mismatch be-
tween outdated management philosophies and those
viewed as more contemporary.
DISCUSSION
The remaining highest-ranking stress-provoking
Even before the COVID-19 pandemic, stress and items were responsibilities of comprehensive patient
burnout among health care providers were a significant care, insecurity concerning professional future, and dif-
concern, as they impact retention in the workforce, med- ficulty in learning clinical procedures. It is not surpris-
ical errors, and patient outcomes. However, the specific ing that in a program that has a heavy clinical
factors impacting stress among orthodontic residents emphasis, residents would feel stressed about learning
in North America have not previously been described. clinical procedures while clinics were closed, at limited
With the onset of the pandemic, stress, burnout, and capacity, or otherwise complicated by an amount of
anxiety among health care providers have increased.26 PPE that was not usual or comfortable to wear. In
This study demonstrated that the primary sources of addition, in a job market with the uncertainty described
stress when the survey was administered were related to earlier, it is understandable that respondents would feel

July 2022  Vol 162  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Khoo et al e39

Table IV. Modified DESQ responses by gender and stage of progress in the program
Distribution of replies, % P values

Stress items n 1 2 3 4 Not pertinent Gender Stage in progress

Self-efficacy beliefs
Lack of confidence to be a successful 231 29.4 28.6 24.7 16.0 1.3 **
orthodontic resident
Lack of confidence in self to be a successful 231 26.4 29.0 25.5 17.7 1.3 **
orthodontist
Completing graduation requirements 219 28.3 31.5 22.8 15.5 1.8
Fear of failing course or year 218 69.7 12.4 5.0 4.6 8.3
Receiving criticism about work 231 41.6 36.4 14.3 3.0 4.8 *
Faculty and administration
Atmosphere created by faculty 231 31.6 31.2 19.9 14.7 2.6 **
Rules and regulations of the program 231 25.5 30.7 25.1 17.3 1.3
Amount of cheating in program 231 63.6 4.3 2.2 0.9 29.0
Expectations of the program and what, in 219 17.8 30.6 29.7 20.1 1.8 **
reality, it is like
Lack of input into the decision-making process 218 16.1 20.6 34.9 25.7 2.8 **
of program
Inconsistency of feedback on work between 219 25.1 31.1 25.1 10.5 8.2
different instructors
Workload
Amount of assigned classwork 241 22.8 27.4 37.3 9.5 2.9
Difficulty of classwork 241 29.5 35.7 28.2 3.7 2.9
Lack of time to do assigned work 219 42.5 31.1 17.4 5.5 3.7 *
Lack of time for relaxation 231 44.2 23.4 20.8 10.0 1.7 *
Fear of being unable to catch up if behind 219 29.7 31.5 21.9 12.3 4.6 ** **
Patient treatment
Responsibilities of comprehensive patient care 240 12.5 20.4 35.4 22.9 8.8
Patients being late or not showing for their 240 22.9 29.2 18.8 12.5 16.7
appointments
Working on patients with dirty mouths 231 31.2 29.9 21.2 9.5 8.2 **
Clinical training
Difficulty in learning clinical procedures 240 12.9 21.7 38.3 19.2 7.9 *
Difficulty in learning precision manual skills 231 21.2 33.3 23.8 13.9 7.8 **
Performance pressure
Examinations and grades 240 31.7 31.7 17.9 7.9 10.8
Competition for grades 239 66.9 10.9 6.3 2.9 13.0
Personal relationships
Relationships with members of the opposite gender 231 79.7 12.1 1.3 2.2 4.8
Martial or relationship adjustment problems 219 43.8 21.0 6.8 5.5 22.8
Forced postponement of marriage or engagement 218 22.5 6.4 3.7 5.5 61.9 *
Having children at home 219 22.4 1.8 4.6 5.5 65.8
Necessity to postpone having children 219 32.0 16.9 8.7 5.0 37.4 **
Conflict with partner over career decision 219 42.9 10.0 3.2 3.7 40.2
Having dual role of wife/mother or husband/father 219 20.5 17.8 10.5 5.5 45.7
and orthodontic resident
Personal life
Personal physical health 218 30.7 37.6 22.0 8.3 1.4 **
Financial responsibilities 219 12.3 23.7 27.4 36.5 0.0
Lack of home atmosphere in living quarters 218 57.3 16.5 10.6 3.7 11.9
Professional life
Insecurity concerning professional future 219 15.5 26.5 31.1 26.5 0.5
Considering entering some other field of work 219 36.1 9.1 6.4 5.0 43.4
Discrimination
Attitude of school toward women dental students 219 58.4 12.3 5.0 4.1 20.1 **
Discrimination because of race, class status, ethnicity, 219 45.2 16.9 8.7 6.8 22.4
or other minority groups

*P \0.05; **P \0.005.

American Journal of Orthodontics and Dentofacial Orthopedics July 2022  Vol 162  Issue 1
e40 Khoo et al

Table V. Anxiety responses by gender and stage of progress in the program

Distribution of replies, % P values

Anxiety items n 1 2 3 4 Gender Stage in program

To what extent are you concerned about COVID-19? 217 10.1 43.3 27.6 18.9 **
To what extent do you believe COVID-19 will have lasting 217 4.6 22.1 36.9 36.4 ** *
impacts on the world?
How likely is it that you could become infected with the 217 8.3 52.5 24.9 14.3 *
novel coronavirus that causes COVID-19?
How likely is it that someone you know could become infected 217 7.4 32.7 35.0 24.9 *
with the novel coronavirus that causes COVID-19?
How much exposure have you had to information about 217 1.4 17.1 49.3 32.3
COVID-19?
If you did become infected with the novel coronavirus that 215 28.8 51.2 12.1 7.9 ** **
causes COVID-19, to what extent are you concerned that
you will become seriously ill?
To what extent has the threat of COVID-19 influenced your 217 7.8 25.8 36.9 29.5 *
decisions to be around people?
To what extent has the threat of COVID-19 influenced your 217 3.7 11.5 27.6 57.1 * *
travel plans?
To what extent has the threat of COVID-19 influenced your 217 1.8 17.5 38.7 41.9 **
use of safety behaviors (eg, hand sanitizer)?

*P \0.05; **P \0.005.

Table VI. Mean total stress and anxiety scores by gender and stage of progress in the program
Stress total score Anxiety total score

Group Mean SD P values Mean SD P values

Gender
Male 1.0 0.59 0.003 2.6 0.58 \0.001
Female 1.3 0.53 2.95 0.52
Stage of progress in the program
First 1.2 0.58 0.66 2.9 0.56 0.015
Middle 1.1 0.54 2.7 0.54
Late 1.2 0.58 2.9 0.56

SD, standard deviation.

stressed about job security and their professional the attitude of the school toward women dental stu-
futures. dents, and forced postponement of marriage or engage-
Residents were least stressed about the amount of ment. This is consistent with previous dental students’
cheating in the program. Cheating has been a concern and residents’ studies, which indicate that personal fac-
in dental schools27,28 as students try to distinguish tors are not highly stress-inducing.17 It is important to
themselves as top performers, especially because the na- note that in most of the 5 lowest-ranked items, residents
tional boards transitioned from numerical scores to a responded: not pertinent, which would also explain why
pass/fail system. However, cheating and competition these items were lowly ranked.
are likely less pronounced in an orthodontic residency When comparing respondents by their stage of prog-
than dental school, as residency certificates are viewed ress in the program, fear of being unable to catch up if
as terminal degrees. behind in the workload category was significantly
The remaining bottom-ranked stress-provoking fac- more stress-inducing for first-year residents than those
tors were primarily related to the category of personal re- further along in the program. This survey was dissemi-
lationships. Respondents did not seem significantly nated between June and July when many residents initi-
stressed about relationships with members of the oppo- ated and concluded their formal orthodontic training.
site gender, conflict with a partner over career decisions, Regardless of their stage in the program, all respondents

July 2022  Vol 162  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Khoo et al e41

had experience with the pandemic impacting their aged \65 years. Therefore, it is logical that respondents
formal training at the time of survey administration. were not highly anxious about contracting or becoming
This included respondents who were fourth-year dental seriously ill from the virus. However, obtaining basic
students in March 2020 and first-year orthodontic resi- items for disinfection during this period, such as hand
dents in July 2020. Those who were first-year residents sanitizer and PPE, were challenging because of interrup-
in June 2020 may have fallen short of program expecta- ted supply chains. Thus it is interesting that respondents
tions regarding the volume of patients seen. If program noted this as a source of anxiety, even though they were
expectations were not adjusted because of the less concerned with contracting the virus. The differ-
pandemic, it is logical that respondents were concerned ences between genders and stages in the program are re-
about being able to catch up. However, when the total flected in the total anxiety scores, which showed that
scores were analyzed for all stress items between stages females and respondents in the middle stages of their
in the program, no significant difference (P \0.05) was program had significantly higher anxiety levels.
identified. Despite the survey clearly stating that the questions
Perhaps the most striking findings of the study are should be answered with respect to the COVID-19
the differences between male and female respondents. pandemic, the authors acknowledge that this study is a
When comparing genders, the total stress scores were snapshot in time and may not be an absolute compari-
highly significant (P \0.005). Across many fields, son to orthodontic residents’ stress and anxiety prepan-
women have been shown to lack confidence compared demic. In addition, at the time of submission, the
with their male counterparts, who are equally or less pandemic has been occurring for well .18 months
qualified.29,30 This gender difference seems to be rooted and continues to dynamically impact societies around
in deep societal gender norms30 and likely preexisted the world. Despite the widespread availability of
among orthodontic residents before the COVID-19 COVID-19 vaccines, there are significant regional differ-
pandemic. Paired with an academic and learning envi- ences with regard to vaccination rate, masking, and
ronment that female residents find more stressful than other public health practices. Recent virus variants,
male residents, our observation that female respondents including the delta and omicron, paired with lifting re-
felt more stressed about learning clinical procedures and strictions meant to keep the public safe, have led to addi-
precision skills is understandable. Academic environ- tional spikes in infections and hospitalizations, causing
ments have been shown to have a profound impact on significant stress on health systems and academic health
learner performance,31 and learning environments centers in many parts of North America. Some dental
within dental schools are rampant with misogyny and programs are scaling back their clinical operations
sexism.32-38 Notably, female residents also relayed a because of the high rate of infections in their commu-
greater amount of stress associated with necessary nities or because of intermittent resources, including
delaying of engagement, marriage, or having children. PPE. The more recent virus variants also infect younger
Finally, the stress associated with discrimination was segments of the population, including vaccinated and
significantly higher among female respondents than unvaccinated subjects. If this study were repeated in
males. Because of the language associated with this the current environment, factors that evoke the highest
item, it is unclear if this is because of gender or other as- amount of stress and anxiety would likely evolve.
pects of the respondents’ identity, such as race, ethnicity, Regardless, the stark differences observed in our study
sexual orientation, religion, ability, or another minority between male and female respondents suggest that or-
status. Although there are more female orthodontic res- thodontic residency programs must evaluate and reflect
idents in the United States than males, most faculty in on the academic environments they create for female
dental schools are White males.39 residents. They must then work with female residents
With regard to the factors that were found to be asso- to make interventions that will allow them to feel
ciated with the greatest amount of anxiety, this study more welcome and less marginalized. Along with estab-
was conducted during the third and fourth months of lishing a more inclusive environment, such actions will
the COVID-19 pandemic, at which time the prevailing inevitably improve performance. Concurrently, program
belief about the severe acute respiratory syndrome coro- directors and professional societies are encouraged to
navirus 2 virus was that it spread by respiratory droplets reflect on the need for workshops, storytelling, and other
and it infected and caused serious illness or death pri- ways for faculty to better understand the experiences of
marily in adults aged .65 years or those with certain female residents. With millennials now accounting for
medical conditions, including obesity. Although medical most orthodontic residents and the majority of faculty
conditions are unknown, it is safe to assume that most, if being from a different generational period, the expecta-
not all, orthodontic residents in North America are tions that female residents have of their working and

American Journal of Orthodontics and Dentofacial Orthopedics July 2022  Vol 162  Issue 1
e42 Khoo et al

learning environment have evolved, and it is critical for REFERENCES

programs to assure that they foster a more contemporary 1. Agency for Healthcare Research and Quality. Physician burnout.
learning environment. Available at: https://www.ahrq.gov/prevention/clinician/ahrq-
As the pandemic continues and hoping that some works/burnout/index.html. Accessed August 21, 2021.
semblance of normalcy will return within the next 2. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of
organizational culture, stress, satisfaction, and burnout with
year, the authors believe it would be valuable to repeat
physician-reported error and suboptimal patient care: results
this study. As more research is conducted on factors from the MEMO study. Health Care Manag Rev 2007;32:203-12.
that specifically impact orthodontic residents’ stress 3. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contribu-
and anxiety, and as residents become increasingly tors, consequences and solutions. J Intern Med 2018;283:516-29.
diverse across gender, race, ethnicity, religion, and other 4. Dyrbye LN, Major-Elechi B, Thapa P, Hays JT, Fraser CH,
Buskirk SJ, et al. Characterization of nonphysician health care
parameters, studying stress and anxiety will become
workers’ burnout and subsequent changes in work effort. JAMA
increasingly important. Chronic stress from the work- Netw Open 2021;4:e2121435.
place leads to burnout, impacting performance, medical 5. Wurm W, Vogel K, Holl A, Ebner C, Bayer D, M€orkl S, et al. Depres-
errors, and productivity. Orthodontic programs should sion-burnout overlap in physicians. PLoS One 2016;11:e0149913.
strive to create safe, welcoming, and nontoxic environ- 6. Dyrbye LN, Major-Elechi B, Hays JT, Fraser CH, Buskirk SJ,
West CP. Relationship Between organizational leadership and
ments for their residents. By studying and understand-
health care employee burnout and satisfaction. Mayo Clin Proc
ing the factors that impact stress and anxiety among 2020;95:698-708.
their residents, programs will be better positioned to 7. National Academies of Sciences, Engineering, and Medicine, Na-
provide a high-quality educational experience that tional Academy of Medicine, Committee on Systems Approaches to
effectively produces technically and emotionally compe- Improve Patient Care by Supporting Clinician Well-Being. Taking Ac-
tion Against Clinician Burnout: A Systems Approach to Professional
tent practitioners for our communities today and
Well-being. Washington, DC: National Academies Press; 2019.
tomorrow. 8. Dyrbye L, Shanafelt T. A narrative review on burnout experienced
by medical students and residents. Med Educ 2016;50:132-49.
CONCLUSIONS 9. Thomas NK. Resident burnout. JAMA 2004;292:2880-9.
This survey-based study demonstrated that while 10. Rubin B, Goldfarb R, Satele D, Graham L. Burnout and distress
among allied health care professionals in a cardiovascular centre
financial responsibilities and travel plans were the of a quaternary hospital network: a cross-sectional survey. CMAJ
most stressful and anxiety-inducing items for ortho- Open 2021;9:E29-37.
dontic residents during the early aspect of the 11. Halbesleben JRB, Wakefield BJ, Wakefield DS, Cooper LB. Nurse
COVID-19 pandemic, multiple items contributed to burnout and patient safety outcomes: nurse safety perception
their stress and anxiety. In addition, both gender versus reporting behavior. West J Nurs Res 2008;30:560-77.
12. World Health Organization. Burn-out an “occupational phenome-
and stage of progress in a residency program impacted non”: International Classification of Diseases. Available at: https://
the level of stress and anxiety reported by respon- www.who.int/news/item/28-05-2019-burn-out-an-occupational-
dents. phenomenon-international-classification-of-diseases. Accessed
August 21, 2021.
AUTHOR CREDIT STATEMENT 13. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al.
Burnout and satisfaction with work-life balance among US physi-
Edmund Khoo contributed to conceptualization, cians relative to the general US population. Arch Intern Med 2012;
methodology, and original draft preparation; Sophia G. 172:1377-85.
Saeed contributed to conceptualization, resources, 14. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al.
manuscript review and editing; Hong-Yan Chiu contrib- Changes in burnout and satisfaction with work-life balance in
physicians and the general US working population between
uted to data curation and formal analysis; Vicky Quach
2011 and 2014. Mayo Clin Proc 2015;90:1600-13.
contributed to data curation and formal analysis; Malvin 15. Brazeau CM, Schroeder R, Rovi S, Boyd L. Relationships between
Janal contributed to formal analysis, manuscript review medical student burnout, empathy, and professionalism climate.
and editing, and visualization; and Kelton Stewart Acad Med 2010;85(10 Suppl):S33-6.
contributed to manuscript review and editing and super- 16. Schmitter M, Liedl M, Beck J, Rammelsberg P. Chronic stress in
medical and dental education. Med Teach 2008;30:97-9.
vision.
17. Divaris K, Polychronopoulou A, Taoufik K, Katsaros C, Eliades T.
Stress and burnout in postgraduate dental education. Eur J Dent
ACKNOWLEDGMENTS Educ 2012;16:35-42.
18. Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG,
The authors would like to express their sincere
Zamakhshary MH. Stress amongst dental students: a systematic re-
thanks to the American Association of Orthodontics view. Eur J Dent Educ 2011;15:8-18.
Partners in Research Program for their assistance in 19. Basudan S, Binanzan N, Alhassan A. Depression, anxiety and stress
this study. in dental students. Int J Med Educ 2017;8:179-86.

July 2022  Vol 162  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Khoo et al e43

20. Barberıa E, Fernandez-Frıas C, Suarez-Cl

ua C, Saavedra D. Analysis 30. O’Neil DA, Hopkins MM. The impact of gendered organizational
of anxiety variables in dental students. Int Dent J 2004;54:445-9. systems on women’s career advancement. Front Psychol 2015;6:
21. Wang Y, Chen X, Yang Y, Cui Y, Xu R. Risk perception and resource 905.
scarcity in food procurement during the early outbreak of COVID- 31. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK.
19. Public Health 2021;195:152-7. How Learning Works: Seven Research-based Principles for Smart
22. Gamio L. The workers who face the greatest coronavirus risk. Available Teaching. 1st ed. Wiley: Jossey-Bass; 2010.
at: https://www.nytimes.com/interactive/2020/03/15/business/ 32. Sinkford JC. Sexual harassment. Commentary. J Dent Educ 1992;
economy/coronavirus-worker-risk.html. Accessed August 21, 2021. 56:610-1.
23. Garbee WH Jr, Zucker SB, Selby GR. Perceived sources of stress 33. Nesbitt PE, Inglehart MR, Sinkford JC. Work environment percep-
among dental students. J Am Dent Assoc 1980;100:853-7. tions of full-time dental educators: does gender matter? J Dent
24. Wheaton MG, Abramowitz JS, Berman NC, Fabricant LE, Educ 2003;67:916-24.
Olatunji BO. Psychological predictors of anxiety in response to 34. Zarkowski P. Simply stated: harassment and gender bias are unac-
the H1N1 (swine flu) pandemic. Cognit Ther Res 2012;36:210-8. ceptable. J Dent Educ 2018;82:1015-6.
25. Jain S, Angural V. Use of Cronbach’s alpha in dental research. Med 35. Tiwana KK, Kutcher MJ, Phillips C, Stein M, Oliver J. Gender issues
Res. Chronicle 2017;4:285-91. in clinical dental education. J Dent Educ 2014;78:401-10.
26. Sharifi M, Asadi-Pooya AA, Mousavi-Roknabadi RS. Burnout among 36. Quick KK. A humanistic environment for dental schools: what are
healthcare providers of COVID-19; a systematic review of epidemi- dental students experiencing? J Dent Educ 2014;78:1629-35.
ology and recommendations. Arch Acad Emerg Med 2020;9:e7. 37. Ivanoff CS, Luan DM, Hottel TL, Andonov B, Ricci Volpato LE,
27. Andrews KG, Smith LA, Henzi D, Demps E. Faculty and student Kumar RR, et al. An international survey of female dental students’
perceptions of academic integrity at U.S. and Canadian dental perceptions about gender bias and sexual misconduct at four
schools. J Dent Educ 2007;71:1027-39. dental schools. J Dent Educ 2018;82:1022-35.
28. Ford PJ, Hughes C. Academic integrity and plagiarism: perceptions 38. Rees CE, Monrouxe LV, Ternan E, Endacott R. Workplace abuse
and experience of staff and students in a school of dentistry: a narratives from dentistry, nursing, pharmacy and physiotherapy
situational analysis of staff and student perspectives. Eur J Dent students: a multi-school qualitative study. Eur J Dent Educ
Educ 2012;16:e180-6. 2015;19:95-106.
29. Vajapey SP, Weber KL, Samora JB. Confidence gap between men 39. American Dental Education Association. ADEA Trends in Dental
and women in medicine: a systematic review. Curr Orthop Pract Education, 2021-22. Available at: https://www.adea.org/
2020;31:494-502. dentedtrends/. Accessed September 17, 2021.

American Journal of Orthodontics and Dentofacial Orthopedics July 2022  Vol 162  Issue 1