Association Among Improper Sleep, Stress And Parafunctional Habits In Dental Students At Dow University Of Health Sciences

Khurram Parvez Sardar¹                                      BDS, MDS

Yashfika Abdul Bari²                                             BDS

Mansoor Akhtar³                                                     BDS

INTRODUCTION

The term “stress”, as it is currently being used was coined by Hans Selye, who defined it as “the non-specific response of the body to any demand for change”¹. The practice of dentistry has long been associated with high levels of occupational stress. Hermanson reported emotional illness ranked third among illnesses in dentists² and Cooper reported the dental profession is the most stressful of all health professions³. People under stress can have insomnia. Insomnia is one of the causes which stress induces and affect the quality of the sleep. It also causes hyperarousal, which makes the balance between sleep and wakefulness distraught. Laboratory evidence shows that fewer sleep durations of 4-5 hours affect physiological and neurobehavioral functioning in a negative way⁴. It is found that bruxism, mainly, as a response to release daily emotional stress; is more common in depressed, anxious and emotionally stressed individuals⁵.

De Leeuw et al consider that muscle dysfunction and associated pain are often the results of stress-induced muscle hyperactivity. The muscle dysfunction determined by the stress can cause changes in the temporomandibular joint⁶. The hyperactivity in elevator mandibular muscles increases intra-articular pressure and biomechanical alterations of temporomandibular joint with the result micro traumatic deterioration of the joint capsule and/or the attachment disc can develop⁷.

The term stress describes external demands (physical or mental) on an individual’s physical and psychological wellbeing⁸. Stressors associated with dentistry include time and scheduling pressures, managing uncooperative patients and the highly technical and intensive nature of work^9-12. This stress can be the prime factor to depression, anxiety, substance misuse, absenteeism, diminished work efficiency, and burnout (a term that describes the experience of long-term work-related exhaustion and diminished interest)¹³. The origin of this occupational stress may have their origin in the educational process as dental students experience high levels of stress during training¹⁴.

The undergraduate education is a delicate period in a student life.  The students from professional courses do feel a great amount of burden in dealing with academic stress and anxiety. This can occur during the transition of the students from an intermediate to a professional academic status¹⁵. Undergraduate students need to cope up with the academic and social demands that they may encounter in university studies in their preparation for professional careers¹⁶.

The parafunction in dentistry refers to those actions of the stomatognathic system that are considered to fall outside of functional activities. Lip and cheek chewing, fingernail biting, and teeth clenching are examples of parafunctional activity. Out of different activities of parafunction, a literature on teeth grinding exceeds the rest¹⁷. Bruxism is an involuntary, parafunctional, excessive grinding, clenching, or rubbing of the teeth^18,19. It is a potentially disparaging habit that results in tooth wear, damage to the structure of the surrounding teeth, inflammation and recession of the gums, increased risk of periodontal disease, muscle pain, and temporomandibular joint (TMJ) dysfunction.’ These symptoms are also associated with headaches, jaw aches, and stiffness or tightening of the shoulders and neck²⁰. It is also reported that individuals with sleep bruxism are three to four times more likely to experience jaw pain and limitation of movement than people who do not experience sleep bruxism^21,22.

The literature has been documented regarding the relationship between neurological and psychiatric and psychopathology and parasomnia (a subgroup of sleep disorders) includes bruxism²³.

It is believed that the stress has universally become a phenomenon that has immensely developed in recent years. The humans have learnt to adapt physiologically to this condition. The stress and the social situation at work are strongly linked to disturbed sleep and impaired awakening, the inability to stop worrying about work during free time generates an important link between stress and sleep leading to parafunctional habits²⁴. Hence, It is important for dental schools to identify stress levels among its students when planning the curriculum and working environment for dental education to create a more student-friendly, less stressful, atmosphere²⁵. Therefore, the aim of the study was to find out the association among stress , insomnia and parafunctional habits according to the academic year of clinical dental students.

METHODOLOGY

It was a descriptive cross-sectional qualitative study carried out using a self- administered questionnaire among undergraduates (second year, third year, and final year) and postgraduates working at dental institutes of Dow University of Health Sciences. The questionnaire covered demographic question, sleep related questions, stress consequences, occupational stressors and stress reduction methods. The data obtained via questionnaire was analysed with SPSS-16. Descriptive analysis was made regarding the data and result was drawn in the form of tables. Chi-square test was used to study the associations between variables. The purpose of this study was communicated to the students, and student participation in the research was voluntary. The response rate was 96.5%.

RESULTS

This study was carried out among undergraduates and postgraduates. Table 1 shows the demographics of the study population. Table 3 showed that more than half of the population go to bed late (n=312, 53.9%) and find difficulty getting into sleep (n=375, 64.8%). Table 3 also represents the consequences of stress respondents suffered..  Out of different consequences, it was found that most common stress-related consequence was grinding their teeth at night (n=322, 55.6%) Table 3 showed the occupational problems that have to be suffered by the students. More than half of the dental students were under occupational stress (n=322,

55.6%) and less than half of the respondents reported to have disturbed academic (n=269, 46.5%) and clinical skills (n=213, 36.8) due to stress. Table 2 is related to stress reduction methods. Respondents were asked that what measure they usually take when in time of stress. Out of the different methods listening music (n=366, 63.2%) was found to be most common stress reduction method. Table 3 also pertains to the association between insomnia and stress and parafunction. This association was found to be significant (p<0.05). Table 3 also shows that the factors which were associated with parafunctional activities was also associated with sleep disturbance and occupational stressors.

DISCUSSION

Dental education is perceived as being stressful course²⁶. The students have a high level of fears and insecurities which make them likely to disturb their mental and physical health. This made the study to choose dental students, as their sample population to highlight the association of stress with improper sleep and developing parafunctional habits^15,16.

It is found that most of the dental and medical students go to bed late due to tough and lengthy academic syllabus and long study hours. Their sleep is improper and they have to further experience daytime sleepiness and tiredness in the morning²⁷. The day time nap becomes important for the students. Waking up too late and having difficulty getting into sleep makes them susceptible to exert pressure on their masticatory muscles and apply external pressure on their occlusal surface of the tooth to release the stress they are going through. This habit for a prolonged period of time makes their temporomandibular joint tender and it becomes painful on opening, closing and chewing. Applying pressure for long hours also makes the muscles numb, so the numbness in mouth was reported^17-22.

The most frequent consequences of stress, according to our study, were feeling restlessness and frustration, teeth grinding, numbness in mouth, pain in temporomandibular joint^9-12. The high prevalence of these consequences was further analysed and it was revealed that high prevalence of difficulty getting sleep was a significant factor in developing these consequences. Therefore improper sleep is to an extent found to be associated with teeth grinding^5,28.

The main result was that the experience of stress was the most signi?cant factor associated with frequent bruxism among the dental students. The bruxers were also found to have pain in temporomandibular joint and they were found to be restless and frustrated^21,22. The study also revealed, there is a significant association found in respondent between difficulty falling asleep and teeth grinding⁵.

The dental students participated in this study were found to have occupational stress. The majority have fear of failure in their examination, unemployment and respondents who had teeth grinding habit also has high level of these fear. 14 Other factors, regarding occupational stressors were also found in respondents who were bruxers and have pain in temporomandibular joint.

This study revealed that stress was found to be associated with sleep disturbance leading to development of parafunctional habits. According to the study, the students who were under high academic pressure were found to be restless and frustrated due to fear of failure and unemployment which leads to their teeth grinding habits and their jaw joint gets affected and they start getting pain in their temporomandibular joint. The study revealed that improper sleep was major factor in developing these habits. It should be recommended that students should take proper sleep in order to get rid of their parafunctional habits and they should use stress reduction methods to get less affected of the stressful conditions. Thus, stress reduction program could be implemented. Such programs for dental students as including specific courses, stress-reduction sessions, introduction to behavioural sciences and faculty incorporated advising systems foster coping behaviours that are useful on a daily basis, as well as preventative measures to reduce chronic stress effects. Students should also be advised to take proper sleep so that students can perform better in their dental environment.

CONCLUSION

It was concluded that there was significant association among improper sleep, stress and parafunctional habits in undergraduate and postgraduate dental students at Dow University of Health Sciences.

Author Contribution:

KPS conceived the project, designed Questionnaire and made significant contribution to reviewing and re-writing of article, YAB contributed to questionnaire designing, data collection, write up of introduction & methodology, MA did the data collection, write-up of results & discussion. Disclosure: None declared.

REFERENCES

1. Selye, H. A Syndrome Produced by various Noxious Agents. Nature 1936; 32-33
2. Hermansonn PC. Dentistry : a harzadous profession. Dent Stud 1972; 50: 60-1
3. Cooper CL, Watts J, Kelly M. Job satisfaction, mental health and job stressors among general dental practitioners in the UK. Br Dent J 1987; 162: 77-81.
4. Minkel J, Banks S, Htaik O, Moreta M, Jones C, McGlinchey E et al. Sleep deprivation and stressors: Evidence for elevated negative affect in response to mild stressors when sleep deprived. Emotion. 2012; 12(5):10151020.
5. Carvalho AL, Cury AA, Garcia RC. Prevalence of bruxism and emotional stress and the association between them in Brazilian police officers. Braz Oral Res. 2008 ;22:31-5..
6. De Leeuw R. Orofacial pain: guidelines for classification, assessment, and management. 4th edition. Chicago: Quintessence Publ. Co.; 2008
7. Praveena KS, Rai R, Easwaran MA, Easwaran B. Temperomandibular disorders Clinical and Modern Method In Differential Diagnosis: IOSR J Dent Med Sci 2014;13:17
8. Kumar S, Dagli RJ, Mathur A, Jain M, Prabu D, Kulkarni S. Perceived sources of stress amongst Indian dental students. Eur J Dent Educ. 2009;13:39-45..
9. Westerman GH, Grandy TG, Ocanto RA, Erskine CG. Perceived sources of stress in the dental school environment. J Dent Educ 1993; 57: 225-231
10. Acharya S. Factors affecting stress among Indian dental students. J Dent Educ 2003; 67: 1140-1148.
11. Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update 1999; 26: 94-98, 100.
12. Rajab LD. Perceived sources of stress among dental students at the University of Jordan. J Dent Educ 2001; 65: 232-241.
13. Tangade PS, Mathur A, Gupta R, ChaudharyS.Assessment of stress level among dental school students: an Indian outlook. Dent resJ2011;8: 95.
14. Freeman R., Main JR, Burke FJ. Occupational stress and dentistry: theory and practice. Part I. Recognition. Br Dent J 1995;178: 214-17.
15. Mane AB, Krishnakumar MK, Niranjan PC, HiremathSG, Mane AB.. Differences in perceived stress and its correlates among students in professional courses. J clindiag resh 2011;5:1228-33.
16.  Pfeiffer D. Academic and Environmental Stress Among Undergraduate and Graduate College Students: ADoctoral University of Wisconsin-Stout, 2001.
17. Bender, Steven D. Occlusion, Function, and Parafunction: Understanding the Dynamics of a Healthy Stomatagnathic System. ADA CERP (2009).
18. Pingitore G, Chrobak V, Petrie J. The social and psychologic factors of bruxism. J Prosthet Dent 1991; 65:443-6.
19. Attanasio R. Nocturnal bruxism and its clinical management. Dent Clin North Am 1991; 35:245-52.
20. Gina P, Chrobak V, Petrie J. “The social and psychologic factors of bruxism.” dentistry Prostht Dent 1991:65; 443-46.
21. Goulet JP, Lund JP, Montplaisir J, Lavigne GJ. Dailyclenching, nocturnal bruxism, and stress and their association with TMD symptoms. J Orofac Pain 1993;7:251-57.
22. Dao TT, Lund JP, Lavigne GJ. Comparison of pain and quality of life in bruxers and patients with myofascial pain of the masticatory muscles. J Orofac Pain. 1994; 8:350-6.
23. Manfredini, D., et al. “Psychic and occlusal factors in bruxers.” Australian Dent J. 2004;49:84-9.
24. Alexander G, Kravitz H, Keith LG, eds. Sleep psychiatry. CRC Press, 2004.
25. Suryalis AM, Yusoff MM, Razak IA. Stress and its relief among undergraduate dental students in Malaysia. Southeast Asian JTropical Med Pub Health 2011;42: 996.
26. Al-Saleh SA, Al-Madi EM, Al-Angari NS, Al-Shehri HA, Shukri MM .,l. “Survey of perceived stress-inducing problems among dental students, Saudi Arabia.”  Saudi Dent J 2010;22:83-8.
27. Johns MW, Dudley HA, Masterton JP. The sleephabits, personality and academic performance of medical students. Med Educ. 1976;10:158-62.
28. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest J 2001;119:53-61.

1. Assistant Professor. Department of Science of Dental Materials Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.
2. House Officer. Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences
3. Department of Prosthodontics Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences

Corresponding author: “Dr. Khurram Parvez Sardar”<dr_khurramaprvez@hotmail.com  >