Chapter 2 Literature Review

Chapter 2: Literature Review Chapter 2: Literature Review The problem of mental health issues in dental professionals has become a burning question in different parts of the world, not only in terms of personal health, but also in clinical practice (Maragha et al., 2025). Mental health, which is generally regarded as the ability of any individual to cope with stressors, self-efficacy, and effective performance within the social and professional context, is of great importance regarding maintaining productivity and the provision of quality care to the patient (D'Amato-Palumbo et al., 2025). Petrovic et al. (2025) showed that dentists and dental hygienists had a high prevalence rate of stress, anxiety, depression, burnout, and substance-related disorders, as compared to the general population. The causes of these challenges were usually related to work overload, working with patients in pain, financial factors, and perfectionistic expectations as a professional. The vulnerability to mental distress was also determined by demographic characteristics, including age and gender: female and younger professionals continuously indicate greater stress and emotional exhaustion (Meira et al., 2020; Molina-Hernandez et al., 2021). Despite the growing literature on mental health in dentistry, a significant gap remains in research into the root causes and lived experiences of depression and anxiety in dentists and dental hygienists, especially in the context of a private practice. The majority of the available research has been quantitative in nature, that is, it is aimed at identifying the prevalence rates but not the individual and situational determinants that influence mental well-being. This gap restricts the knowledge on how these professionals perceive, experience, and manage their workplace mental health challenges. Thus, the qualitative phenomenological research aims to determine the lived experiences of dentists and dental hygienists working in the private practice setting in California in relation to the mental health issue concerning the problem of depression and anxiety. This study will offer a perspective on the effects and impact of occupational stressors and the work environment on psychological well-being and direct future intervention and research to support the maintenance of the mental health of dental practice. Literature Search Strategy A comprehensive literature search of the evidence on mental health issues in dentistry was conducted using Google Scholar. The search terms employed included "dentists," "dental hygienists," "depressive symptoms," "depression," "anxiety," "private practice," "mental health," "dental healthcare workers," "coping," "psychological distress," and "burnout." The custom range for Google Scholar was set to 2020 to ensure all studies included in the review are published within the last five years, that is, 2020 to 2025. Articles were read for relevance to ensure they were peer-reviewed and reputable enough to be included as scholarly articles. Theoretical Framework The Job Demands-Resources (JD-R) model and the transactional theory of stress offer the theoretical basis of the literature review. The JD-R model was introduced over two decades ago (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001). The transactional theory of stress and coping was founded over four decades ago (Lazarus & Folkman, 1984). Both theories can be applied to dentistry to understand issues related to job demands and resources and how they contribute to well-being and mental health outcomes in relation to different practice environments. More specifically, implementing JD-R-based approaches will likely allow dentists and dental hygienists to evaluate job demands within their private practice settings and establish possible resources to support their well-being and practice outcomes. Job Demands-Resources Model (JD-R) The JD-R theory holds that different aspects of the working environment, including working conditions, can be categorized as job resources and demands. A job demand, for example, might be difficult in using new technology to deliver dental services, thus causing the dentist to develop anxiety. In this case, a job resource would be the exact opposite, whereby the dentist has the right training and expertise to use the new solution to deliver care services, thus contributing to reduced feelings of worry or anxiety within the practice context. The JD-R model was coined by Demerouti et al. (2021) to offer a framework to understand how job resources and demands impact employee performance and well-being. JD-R proposed a dual-procedure framework by associating job demands like stress and workloads with job resources, like support and autonomy (Demerouti et al., 2001). For people, Zhou et al. (2022) defined a strain as a response to a disequilibrium between job resources and job demands. Thus, the availability or absence of either job resources or job demands typically contributes to the development of mental health issues like depression and anxiety. Job Demands Job demands can be understood as aspects of the job that demand constant psychological or physical skills or efforts and are thus linked to specific psychological or physiological costs, like job insecurity, disagreements with others, and heightened work pressure (Zhou et al., 2022). Job demands could have a substantial impact on the performance of dentists and dental hygienists. Job demands significantly impact the performance of dentists, affecting different areas of workplace performance and well-being. Since job demands require significant effort from the dental professional, it can result in stress and anxiety, particularly in scenarios where support or resources are low or demands are quite high. Thus, the JD-R model offered a model of understanding outcomes, including burnout and mental health issues (Kazar & Rahmanzadeh, 2024). The heavy workloads, physical and mental work demands, and work intensity affect the mental health and general well-being of dental health professionals in a disadvantageous way. The COVID-19 period was characterized by infection control and prevention measures, and it is possible that healthcare professionals, including dentists and dental hygienists, face specific new demands. As an illustration, such habitual activities of dental workers needed to be incorporated as virus testing, self-protective tactics, and epidemic research. The employees in the healthcare facility were not satisfied that they were required to always take precautions. According to Zhou et al. (2022), the infection control and prevention measures that reduced workplace autonomy worsened anxiety and burnout. Social stress factors were also common in those cases when the supervisors, colleagues, and patients had to be regularly updated on the infection control and prevention measures. Consequently, new work-related stressors are affecting the mental health of dental professionals in the contemporary age. Job Resources Job resources are seen as positive job characteristics that are necessary to achieve work goals, reduce the psychological and physical expenditures of job pressures, and enhance personal growth (Zhou et al., 2022). These resources do not exist in a monolithic form at the workplace; they operate at a number of interrelated levels. This involves the task level, which comprises work on the skills application and clinical decisions autonomy; the social and interpersonal level, which consists of positive supervisor feedback and supportive workmates; and the organizational level, which entails participatory leadership, clear policies, and positive safety culture. These necessities are of particular significance to the challenging profession of dentistry. It is expected that these job resources will be highly motivational to the dental health professionals. Such resources help to augment work engagement, heighten professional efficacy, and provide counteractions to the adverse influence of excessive job demand through providing the necessary tools, assistance, and positive working setting. Ultimately, they will be critical in ensuring the long-term health and well-being of the employee, avoiding burnout, and ensuring the sustainability of the career. Social support is an important resource as an individual seeks to cope with work-related stressors. Social support was found to have a positive correlation with an individual's well-being but has a negative association with burnout among medical professionals, particularly during the COVID-19 era (Moisoglou et al., 2024). When an individual perceives that they lack social support, they are likely to develop anxiety, stress, inadequate sleep, and depression. Social support was found to moderately impact work-related stress among other populations, although not in the current era of COVID-19 (Zhou et al., 2022). Thus, social support is negatively related to anxiety, depression, and burnout while moderating the impact of COVID-19-associated workplace burnout and stressors and healthcare professionals' well-being. Organizational support is an essential protective factor for dental professionals, particularly in epidemic circumstances. There are two reasons for making such an assertion. First, only healthcare facilities have the capacity to offer enough practical personal protection equipment and education on the treatment and prevention of illnesses. Second, healthcare workers, including dentists and dental professionals, could be supported or motivated in a supportive healthcare practice landscape (Zhou et al., 2022). Transactional Theory of Stress The transactional theory of stress and coping was developed by Lazarus and Folkman in 1984. According to these seminal authors, stress and coping should be conceived as increasingly interrelated processes anchored on the interaction of a person with their immediate environment perceptions (Lazarus & Folkman, 1984). Thus, the theory assumes that there is an interaction or situation that is inherently stressful in itself; it is the appraisal or perception of the situation that makes a person experience anxiety or stress. The transactional theory of stress conceptualizes stress as emanating from the interaction between appraisal and coping processes. The former entails distinct forms of thinking frameworks of primary and secondary appraisals. The primary appraisal entails evaluating the importance or relevance of a situation to the individual's needs and thus helps establish whether it incorporates a challenge or threat to oneself. Spătaru et al. (2024) found that if an individual perceived that they were unable to handle the stressor, then it was deemed harmful and constituted a threat. For example, when practicing within the COVID-19 era, dentists and dental hygienists constantly appraised the stress of such an external event, as De-Cordova et al. (2024) noted. In the secondary appraisal process, individuals evaluated their coping ability by deciding on a workable strategy and analyzing its chances of success, anticipated outcomes, and its appropriateness. The initiation of coping mechanisms was a dynamic process between an individual and an environment that resulted in the continuation of the situational assessment (Spătaru et al., 2024). As an example, the interaction of the internal and external demands was observed when dental professionals were engaged in the secondary appraisal phase. The external demands were factors that are beyond the control of the dentist (De-Cordova et al., 2024). Human beings tended to re-review their realities, particularly in stressful cases where some of their judgmental and coping systems are elicited by the environment. This assertion is based on the assumption that there is no determined temporal order between coping and appraisal. Thus, the transactional theory of stress argued that stress assessments are increasingly dynamic and change from one scenario to another, making daily appraisals unstable (Spătaru et al., 2024). For example, emotionally strained dental professionals were likely to negatively interpret their practice or work environment over time due to the inability to obtain and store job resources and sustain workplace engagement, particularly in scenarios where the job demands are quite burdensome, and the professional has deteriorated affective health (Spătaru et al., 2024). Therefore, the transactional theory of stress is vital when seeking to understand the relationship between workplace anxiety and coping mechanisms. Research Literature Review Geisinger and Dershewitz's (2022) commentary contributed to the understanding of mental health in dental practice and the impact of stress on professional and personal functioning, and offers a call to action. The researchers' call to action involved steps to foster the identification and mitigation of psychological health issues for dental healthcare professionals and reduce the stigma linked to mental health disorders (Geisinger & Dershewitz, 2022). They noted that the symptoms of depression and anxiety were different between dental hygienists and dentists during the COVID-19 era, taking other factors constant, including practice type, geographic area, practice experience, and gender. Dental professionals were seen to be struggling with occupation-specific and societal stressors, and these have increased because of the pandemic. When these issues were left unaddressed, the professional and personal functioning of these professionals was at risk, particularly due to anxiety and depressive manifestations. These mood disorders (i.e., anxiety and depressive symptoms) that dental professionals experienced led to difficulties in maintaining health, interpersonal functioning, and relationships (Geisinger & Dershewitz, 2022). The occupation-related stressors were understood as job demands via the JD-R model, whereby dentists faced the need to sustain concentration, achieve optimal precision thresholds, and emotional toll related to managing patient anxieties and expectations (Johnson, 2025). The first step was putting in place training programs on clinical manifestations of stress, anxiety, and burnout. Second, the researchers recommended that dental practitioners put a greater emphasis on the development and management of self-care plans. Third, the primary aspect of continuous training would be self-care techniques. The fourth step was to ensure that peer support plans have self-care and mental health services. Lastly, to ensure that the dentists and dental hygienists were connected to the psychological healthcare providers, the information must easily be found by national, state, and local dental organizations. Finally, Geisinger and Dershewitz (2022) noted that there should be systematic attempts to define factors that prevent dental healthcare workers from seeking treatment (Geisinger & Dershewitz, 2022). Hence, all dental professionals in the present practice scenario required better mental health provision. Johnson (2025) asserted that, as they served as a buffer to facilitate the fulfillment of work goals, reduced job demand, and emphasized personal development, learning, and growth, they would be considered job resources, and stress, anxiety, depression, and burnout levels among dental workers remained a matter of concern worldwide. It was demonstrated in research that stress, anxiety, depression, and burnout were highly prevalent in most practice and academic settings, which proved the finding that the mental health of dental workers remains a significant concern on a global scale. Johnson (2025) also contextualized this crisis by noting that some demographic and organizational processes, and the especially stressful environment of dental practice, were all interlocking factors that positively impact the poor psychological performance of dental professionals. One such example was that a high-pressure background was developed through hard interactions with patients, perfectionist demands, and high-stakes clinical practice. This was aggravated by organizational problems such as lack of autonomy, unsupportive management, and profit-driven models of practice, which was also increased by demographic susceptibility, such as women and professionals early in their careers, who often reported disproportionately high levels of distress. The available literature was insinuating that occupational stress in dentistry was not only pervasive but equally layered. It was at the complicated crossroads, or convergence, of widespread environmental stressors, vulnerabilities of age and experience, gender-related pressures, and an excessive workload in clinical work. This combination of differing factors jeopardized the welfare of dental professionals all over the world. Geisinger and Dershewitz (2022) stated that anxiety and depression are typical mental health problems in dentists and adversely affect their lives and productivity. Based on their results, these mental health issues deteriorated interpersonal relationships, reduced career satisfaction, and contributed to professional burnout. Notably, they demanded structural and institutional changes, including the availability of peer support, lifelong education on self-care, and an organized checkup on mental health, to normalize mental health care in the dental profession. The recommendations were very consistent with the discussion of Johnson (2025) concerning the Job Demands-Resources (JD-R) model, which theorized the mental health support systems as crucial job resources that address the occupational stress, boost motivation, and increase engagement. Collectively, these studies highlighted that organizational and social resources protected against the negative impacts of stressful work conditions in dentistry. Psychological burden in the dental setting was also applicable to the academic setting, where work overload, performance stress, and conflicting requirements are additional causes of stress and reduced quality of life (QoL). Meira et al. (2020) discovered that there was a significant negative correlation between quality of life and perceived stress in dental faculty, especially among women and younger professionals. Women dental teachers expressed more stress and lower QoL scores, and the causes of stress tended to be long work hours, use of medication to mitigate the work strain, and a lack of leisure time. These results were similar to those of Molina-Hernandez et al. (2021), who also found that dental professionals of younger age and females were more prone to higher emotional burnout and job dissatisfaction. The overlap of these findings indicated that demographic factors, especially gender and age, were relevant in the determination of mental health outcomes in education and clinical settings. By managing these differences by equally distributing the working load, gender sensitive wellness systems, and providing better institutional support, stress would be minimized, and the well-being of both dental educators and practitioners would be improved. The effects of external crises on mental health were another theme that reoccurred, especially after the COVID-19 pandemic. According to Eldridge et al. (2022), anxiety and depression symptoms surged among dental professionals in the United States, reaching their highest...