original article
Wien Med Wochenschr (2015) 165:100–106
DOI 10.1007/s10354-014-0341-6
Prevention of study-related stress symptoms:
health-promoting behavior among dental students
Stefanie Mache · Karin Vitzthum · David A. Groneberg
Received: 30 September 2014 / Accepted: 29 December 2014 / Published online: 28 January 2015
© Springer-Verlag Wien 2015
Summary
Background  Training to become a dentist is one of the
most demanding professional education experiences.
There are very few studies on strategies and activities to
cope with study-related stress during dental training. We
therefore evaluated the prevalence of burnout symptoms
and coping activities among dental students.
Methods  A cross-sectional survey was performed
analyzing a sample of 239 dental students from Germany.
Students were asked to complete a survey containing
questions about burnout symptoms and coping behavior.
Results  A total of 38 % of the dental students perceived
symptoms of emotional exhaustion; 17 % reported symp-
toms of personal accomplishment and 11 % perceived
scores of depersonalization. Students reported on coping
activities, ranging from health-promoting techniques,
such as exercising, to less recommendable health harm-
ing relaxation strategies, such as taking drugs.
Conclusion Our results indicate the need for relevant
health promotion and may aid decision makers in devel-
oping health promotion programs.
S. Mache, PhD, MSc, MHA ()
Institute for Occupational and Maritime Medicine (ZfAM),
University Medical Center Hamburg-Eppendorf,
Seewartenstraße 10,
Haus 1, 20459 Hamburg, Germany
e-mail: stefanie.mache@bgv.hamburg.de
Prof. D. A. Groneberg, MD · S. Mache, PhD, MSc, MHA
Institute of Occupational Medicine, Social Medicine and
Environmental Medicine, Johann Wolfgang Goethe-University,
Theodor-Stern-Kai 7,
60590 Frankfurt a. M, Germany
K. Vitzthum, PhD, MSc
Institute of Occupational Medicine, Charité—Universitätsmedizin
Berlin, Free University and Humboldt University,
Thielallee 69–73,
14195 Berlin, Germany
100   Prevention of study-related stress symptoms: health-promoting behavior among dental students
Keywords  Burnout  · Dental education  · Health-pro-
moting behavior · Medical performance · Study-related
stress
Bewältigung von psychomentalen Belastungen
im Studium: Coping-Verhalten unter
Zahnmedizinstudenten
Zusammenfassung
Hintergrund  Das Studium der Zahnmedizin ist durch
hohe Anforderungen gekennzeichnet und stellt eines
der herausforderndsten universitären Ausbildungswege
dar. Es werden häufig psychosoziale Probleme während
des Studiums berichtet. Bewältigungsmöglichkeiten im
Umgang mit Studienherausforderungen werden in der
Ausbildung bislang nur unzureichend vermittelt.
Die vorliegende Studie soll einen aktuellen Einblick in
die Prävalenz psychischer Probleme (in Form der Burn-
out Symptomatik) unter Studierenden geben. Ebenso soll
ein Überblick vermittelt werden, wie Studenten mit den
Herausforderungen im Studium umgehen, bzw. welche
Bewältigungsstrategien eingesetzt werden.
Methodik  Eine querschnittliche Fragebogenerhe-
bung wurde durchgeführt, die 239 Studenten der Zahn-
medizin einbezog. Die Studenten wurden gebeten, einen
Online-Fragebogen auszufüllen, der aus dem Maslach
Burnout Inventory sowie Angaben zu individuellen
Stressbewältigungsstragien bestand.
Ergebnisse  Die subjektive Einschätzung psychischer
Probleme zeigt eine mittlere Ausprägung. Bewälti-
gungsstrategien rangieren im Bereich gesundheitsför-
derlicher Maßnahmen (z. B. Ausgleich durch Sport) bis
zu potenziell gesundheitsschädlichen Strategien (z.  B.
Drogenkonsum).
Schlußfolgerung Ein umfassender Einsatz von Auf­
klärungs- und Gesundheitsförderungsprogrammen wäh­
rend des Zahnmedizinstudiums ist zwingend erforderlich.
13

Schlüsselwörter Burnout · Gesundheitsförderung · Co-
ping · Stress · Studium
Introduction
In 2013, 14,820 students were enrolled in a German fac-
ulty of dentistry [1]. Dental education is known as one of
the most demanding fields of study. It includes numer-
ous sources of stress such as academic pressure, long
working hours, enormous amounts of learning mate-
rial, clinical problems, etc. [2]. Student drop-out from
German dental schools is approximately 5 % per study
year [3].
Previously published studies showed that den-
tal students are currently affected by stress: students
show symptoms of emotional exhaustion (EE), com-
plain about a high degree of psychological distress,
and perform less than in earlier times [4]. However,
potential stressors may have harmful effects on dental
students’ mental or/and physical health [5]. Experienc-
ing high levels of stress may result in burnout, a term
that describes the experience of long-term work-related
exhaustion and diminished interest [6]. Although, many
studies described burnout as a “professional syndrome”
some investigations showed that burnout symptoms can
also be found among students [7]. Researchers these
days considered burnout symptoms as a typical distress
in the educational process. For example, in the medical
field, recent studies by Dyrbye et al. [8] have investigated
that up to 50 % of medical students show symptoms of
burnout.
To deal with study pressure and workloads, students have
to prevent suffering from symptoms of burnout. Therefore,
there is a strong need for dental students to take a time-out
after daily studies and to renew their subjective energy lev-
els. Prevention strategies can help dental students avoid
stress-related disorders. Previous research studies have
shown a positive association between using relaxation tech-
niques and coping with stress [9, 10].
A huge variety of relaxation activities and special tech-
niques exist. They can be categorized into health promot-
ing and harming relaxation activities. Health promoting
relaxation activities are, for example, exercising/playing
sports, yoga, healthy eating behavior, etc. Harming and
unfavorable relaxation activities are, e.g., taking drugs/
tranquillizers, smoking, drinking alcohol, etc.
Most of the published studies in this research field
refer to harming relaxation activities such as alcohol
and other drug abusive behaviors [11, 12]. Many inves-
tigations have focused on students’ consuming behavior
regarding these substances. Students often reported that
they smoke cigarettes to manage high levels of distress
[13]. Further research studies have indicated that another
means by which young people cope with psychological
distress is the consumption of alcohol [14].
There are only few studies focusing on students’
health promoting coping and relaxation activities; par-
ticularly on dental students. Studies focused either on
13 Prevention of study-related stress symptoms: health-promoting behavior among dental students   101
original article
the prevalence of health promoting relaxation activities
or investigated the influence on students’ stress percep-
tion, health, and performance.
Aims of the study
The aims of the present study were: First, to describe the
prevalence of burnout symptoms among dental students;
second, to focus on dental students’ relaxation activities;
third, to investigate gender differences with regard to
burnout symptoms and relaxation activities. Finally, we
aimed to investigate associations between burnout and
relaxation activities among dental students.
This study aimed to address the following research
questions:
1. To what extent are burnout symptoms perceived by
dental students?
2. What kind of relaxing strategies do German students
use to cope with daily hassles?
3. Are there gender differences among German dental
students regarding perceived burnout symptoms?
4. Are there gender differences with regard to coping
activities?
5. Are there significant associations between burnout
symptoms and relaxing activities?
Methods
This cross-sectional survey study was conducted
between 2012 and 2013. The study design consisted of
distribution of an e-mail that invited dental students to
participate in a survey by following a link to a web-based
questionnaire. Participation in the study was voluntary
and anonymous.
Dental students of a university in the north of Ger-
many (at the Charité—Universitaetsmedizin Berlin) were
asked to fill out an anonymous online questionnaire
about their perception of individual burnout symptoms
and their personal use of different drugs, stimulants, and
relaxation activities. The initial mailing list contained
about 405 dental students enrolled at the university.
Semesters 1–14 were included in the study. Totally, 239
questionnaires were analyzed (128 women/111 men).
Response rate was 59 %. We performed a sample size
determination and power analyses to review and verify
statistical power.
Instrument
1. Sociodemographic data
The survey included questions regarding burnout, relax-
ation activities and sociodemographic variables. The ini-
tial items on the questionnaire pertained to the students’
demographic characteristics, including gender, age,
 original article

marital status, and number of study terms (completed Table 1  Absolute and relative frequencies of coping and re-
semesters). laxation activities (used at least once in a lifetime)
Dental students
2. Burnout inventory
n %

Burnout was measured using the three dimensions of the Meeting friends 197 83
22-item Maslach Burnout Inventory (MBI) [15, 16]. We Sleeping 189 80
used the German version of the MBI [17]. Healthy diet 185 78
Subdimensions are emotional exhaustion (EE; nine Exercising 182 77
items), depersonalization (DP; five items) and personal Watching TV 169 72
accomplishment (PA; eight items). Items were rated
Walking 166 70
on a 7-point scale (0 = “never,” 1 = “a few times a year,”
Cooking 163 69
2 = “monthly,” 3 = “a few times a month,” 4 = “weekly,”
5 = “a few times a week,” and 6 = “every day”). The sub- Drinking alcohol 125 53
scales were added up to a total value. Maslach et al. Spa treatments 116 49
defined that burnout is present if the total value of the Caffeine 102 43
sub-scales EE and DP are high and the value for PA is Yoga, PMR 71 30
low. Maslach et al. specified cut-off values in their third Smoking cigarettes 68 29
edition of the Maslach Burnout Inventory specifically
Cannabis/marijuana 19 8
for the medical field [16]. Cut-off values were specified
as followed: for EE, it is the sum value of ≥ 18, for DP, Sedatives 11 4
≥ 10 and for the PA, ≤ 33 [17]. Burnout is indicated if Performance enhancing stimulants 3 1.4
the values are above these cut-offs [16]. Quality criteria Cocaine/heroin 2 0.8
(e.g., reliability, internal consistency) have been proven Ecstasy 1 0.4
for the German version [17]. PMR progressive muscle relaxation
We also evaluated the quality criteria and found sat-
isfactory values: EE, Cronbach’s α = 0.80; DP, Cronbach’s
α = 0.69 and PA, Cronbach’s α = 0.76. Chi-square analyzes were used to test for differences
in frequency of use by sex, age, and number of terms.
3. Coping activity scale We analyzed the data with regard to their distribution
and consequently used parametric and nonparamet-
The following items pertained to the participants’ prac- ric tests. All differences or correlations were consid-
tice of relaxing activity items, explored by a multiple ered to be statistically significant at P < .05-level. T-tests
choice list. The content of the list was developed at the were used to analyze gender differences with regard to
Department of Occupational Medicine and proved by burnout symptoms and coping/relaxation activities.
the Department of Neurology at the Charité—Univer- Pearson’s and Spearman’s correlation coefficients were
sitaetsmedizin Berlin for its completeness and correct- analyzed to investigate on associations between burn-
ness. An overview of all relaxation activities included in out symptoms and coping/relaxation activities. For the
this study is shown in Table 1. correlation analyses we only analyzed data from those
The response options that were used for the coping students who had chosen response option 4 (often) or
and relaxing activities items followed the same pattern 5 (always) and calculated correlations with the equiva-
of ascending frequency as similar questionnaires in that lent MBI scores.
research field. The first question contained a table of An α-level of 0.05 was used for each statistical testing.
coping/relaxation activities (see Table 1). Students were Statistical analyses were performed using SPSS for Win-
asked if they had used one of these activities at least once dows Version 19.0.
in their lifetime (yes/no). In addition, we asked on fre-
quency of usage for each coping activity depending on Ethics:  All procedures followed were in accordance with
the answer of the first question (only if verified). the ethical standards of the responsible committee on
The response options were “never in my life” (1 = never), human experimentation and with the Helsinki Declara-
“have done or used but not in the last 2 months” tion of 1975.
(2 = rarely), “once in the last 2 months” (3 = sometimes),
“more than twice in the last two months” (4 = often) and
“every day or nearly every day” (5 = always). Results

The average age ± SD of the total sample was 23 ± 4.47

Statistical analysis years. The final sample was 64 % women and 36 % men.
At the time of the survey, the mean number of terms
At first, we analyzed descriptive statistics (frequencies, (German semesters) that had been completed by the stu-
percentages, means, and standard deviations (SDs)). dent subsample was 6 ± 4.11. In all, 12 % were married;

102   Prevention of study-related stress symptoms: health-promoting behavior among dental students 13
 original article

Table 2  Burnout subdimension scores divided by age and students (n.s.; P > .05). However, the T-test results also
gender showed that significant gender differences were found
Burnout in the subdimensions EE and DP (P < .05). Female den-
Emotional exhaus- Depersonalization Personal accomplish-
tal students rated EE significantly higher than male stu-
tion (range 0–54) (range 0–54) ment (range 0–48)
dents (M = 19.62; SD = 9.37/M = 17.25; SD = 8.74, P < .05).
In contrast, male students rated DP significantly higher
Mean (SD)
than female students (M = 7.63; SD = 4.95/M = 5.15;
Overall 18.1 (8.8) 6.5 (4.8) 31.3 (7.9) SD = 3.51, P < .05). Reduced PA was perceived higher
Age by male students than by female students (M = 32.4;
  < 20 19.1 (7.3) 5.5 (3.4) 27.9 (3.8) SD = 8.1/M = 30.2; SD = 7.9), but this result did not reach
 21–25 19.8 (9.2) 6.2 (4.2) 29.4 (5.3) significance; n.s., P > .05).
 26–30 18.7 (8.9) 6.9 (5.1) 31.8 (7.9)
  > 30 17.3 (8.1) 7.1 (5.5) 32.8 (8.2)
Coping and relaxation strategies
Gender
 Female 19.62 (9.3) 5.1 (3.5) 30.2 (7.9) Table 1 illustrates absolute and relative frequencies of all
 Male 17.25 (8.7) 7.6 (4.9) 32.4 (8.1) coping/relaxation activities reported to be performed/
done/used by the participating dental students at least
once in a lifetime. As shown, the most common relaxation
the remainders were single or at least not living with a activities were meeting friends (83 % of the participating
partner. students) and sleeping (80 %). In addition, Table  1 also
illustrates frequencies for “eating healthy food” (78 %),
“watching TV” (72 %), and “going for a walk” (70 %) as
Burnout three relaxation strategies. More unhealthy activities were
also reported, such as drinking alcohol (53 %) and smok-
Our results show moderate burnout scores being per- ing cigarettes (29 %). Taking drugs to relax was reported
ceived by the dental students. An overview of all subdi- relatively rare; 0.4 % of the students reported taking
mensions of burnout is illustrated in Table 2. ecstasy, 0.8 % mentioned taking cocaine, heroin and 1.4 %
With regard to the three burnout dimensions, the described taking performance enhancing substances, e.g.,
subdimension EE had a mean of M = 18.1 (SD = 12.83). amphetamines. Of the students, 8 % mentioned that they
A total of 38 % of the dental students (n = 91) perceived have used cannabis and marijuana at least once in their
symptoms of EE (≥ 18). The burnout symptom PA stands lifetime. Sedatives and tranquillizers have been taken by
for a decrease of performance during the course of their 4.5 % of the participating students at least once.
dental medicine studies; 17 % of the students (n = 40) In addition, Table  3 gives more detailed information
reported sum scores of PA ≤ 33. The scale was scored with about the frequency of usage.
M = 31.4; SD = 7.6.
The subdimension DP was scored with M  = 
6.5
(SD = 4.83); 11 % of the dental students reported scores of Gender differences
DP ≥ 10 (n = 26).
T-tests showed that the overall scores for burnout We found significant gender differences in relaxation
did not significantly differ between female and male activities (see Table  4): Male students smoke cigarettes,

Table 3  Coping and relaxation activities among dental students: absolute and relative frequency of use
Coping and relaxation activities Frequency of use
Never (n/%) Seldom (n/%) Sometimes (n/%) Often (n/%) Always (n/%) n.a. (n/%)
Meeting friends 2/1 17/7.1 63/26.2 106/44.3 19/7.9 32/13.4
Sleeping 7/3 38/15.7 62/25.5 81/34.1 19/8.1 32/13.4
Healthy diet 13/5.6 47/19.5 59/24.6 65/27.4 22/9.3 32/13.4
Exercising 15/6.1 45/18.7 61/25.7 66/27.8 19/7.9 33/14.0
Walking 16/6.5 39/16.3 65/27.4 79/33.1 9/3.6 31/13.1
Watching TV 23/9.8 36/15.2 61/25.5 76/31.6 11/4.5 32/13.4
Drinking Alcohol 75/31.3 60/25 49/20.7 20/8.3 2/0.7 33/14.0
Smoking cigarettes 155/64.7 12/4.9 11/4.7 17/7.2 10/4.1 34/14.3
Cannabis/Marijuana 186/77.9 11/4.7 5/2.2 2/0.9 1/0.2 34/14.2
Caffeine 112/46.9 32/13.2 29/12.1 25/10.5 8/3.2 34/14.2
n.a. not answered

13 Prevention of study-related stress symptoms: health-promoting behavior among dental students   103
 original article

Table 4  Gender differences in relaxation activities Burnout among dental students

Relaxation activities Male students Female students
Our results demonstrate that 38 % of the dental students
Mean (SD) scored above the recommended cut-off values in EE,
Exercising 3.25 (1.1) 3.08 (1.2) 11 % in DP, and 17 % in PA. The values for the MBI of this
Eating healthy food 2.92 (1.0) 3.33 (1.1) study do match previously published values from dif-
Cooking 2.59 (1.1) 2.89 (0.9) ferent studies. Similarities and differences were found
Walking 2.50 (1.1) 2.86 (1.0)
comparing our study results to former published results
between other dental and medical students. The study by
Spa/wellness 1.57 (0.8) 2.13 (0.9)
Guthrie et al. demonstrated the following burnout symp-
Yoga 1.31 (0.7) 1.79 (1.1) tom rates: 14.0–16.1 % for reduced PA, 9.6–12.9 % for EE,
Drinking alcohol 2.39 (1.1) 1.92 (0.9) and 3.8− 7.1 % for the DP sum scale [18]. In a more recent
Smoking 1.78 (1.3) 1.51 (1.1) study in dental students, 10 % had high scores of EE, 17 %
Taking cannabis/marijuana 1.23 (0.6) 1.09 (0.4) regarding PA and 28 % regarding DP [19].
Significant gender differences were also found in the
subdimensions. Female students have scored significantly
higher on EE than on DP and decrease of performance.
take cannabis and/or marijuana and drink alcohol signif- Male students, in contrast, rated significantly higher on
icantly more often than their female colleagues (P < .001). DP than on EE. These gender differences in the subdimen-
This difference has also been found for doing more exer- sions have also been found by Amin et al. [20]. Our find-
cises as a relaxation strategy (P < .001) (Table 4). In con- ings are also in-line with previous investigations among
trast, female students try to do more walking, yoga or spa dental students performed in various countries [21, 22].
wellness (P < .001). Female dental students try to relax
more often by cooking and/or by eating healthier food
(P < .001) (Table 4). Coping and relaxation activities
We found no significant gender difference with regard
to the following relaxing activities: watching TV, sleep- One of the most common favorable coping activities
ing, meeting friends, taking illicit drugs (e.g., ecstasy, were talking to and meeting friends. Previous research
cocaine), sedatives, cognitive enhancing substances confirmed that relationships and friendships have a pos-
(e.g., amphetamine) or uppers (e.g. caffeine). itive impact on health in general, particularly on men-
No significant differences could be found regarding tal health, as an act of social support [23–25]. Our data
sociodemographic variables such as age, field of study or also showed that exercising, yoga, etc. are activities often
number of semester. practiced by students to relax. As illustrated in previ-
ous studies there is a positive impact of these relaxation
activities on mental health, cardiovascular diseases, and
Associations between burnout and relaxation musculosceletal disorders. Previous study results show
strategies evidence that physical activity in general improves psy-
chological well-being [26, 27].
We found five small, but significant correlations between Only few students reported using drugs such as mari-
burnout symptoms and coping activities in the expected juana, cannabis, or other illicit stimulants for relaxation.
directions: meeting friends (EE: r = − .16, P < .01; DP: This is similar to findings of other studies demonstrating
r = − .11, P < .05), exercising (EE: r = − .11, P < .05; DP: comparable prevalence [28]. Compared with the use of
r = − .10, P < .05), taking sedatives (EE: r = .17, P < .01; DP: illicit drugs, drinking alcohol was more commonly used
r = .12, P < .05), taking performance enhancing stimu- for relaxation. Acute alcohol intoxication generally causes
lants (PA: r = .15; P < .01), and taking cannabis/marijuana short- or long-term health effects [29]. This conflicts
(DP: r = .10, P < .05). with binge drinking behavior which is becoming more
and more prevalent, especially in an even younger Ger-
man population [30–32]. It can harm physical and mental
Discussion health in the long term, and may lead to addiction [33].

The present study evaluated perceived burnout symp-

toms in combination with the practice of relaxation
activities in a large, random sample of dental students
in Germany. The results add to the knowledge base of
prevention strategies on how to handle study-related
stress and provide valuable information on associations
between burnout symptoms and coping behavior in the
dental education field.
Gender differences
Our study results have shown several gender differences
in relaxation behavior. It seems as if female students try
to relax in a healthier way than male students.
Previous health promotion studies have confirmed
these results. A study by Peker et al. [34] illustrated that

104   Prevention of study-related stress symptoms: health-promoting behavior among dental students 13

female students engage in more responsible health
behaviors. Significant associations were found between
overall health-promoting lifestyle behaviors, health
value, stress, and social support. In addition, our results
illustrated that women try to eat healthier compared with
male students, especially in stress situations. Previous
studies focusing on gender differences in eating behavior
confirm our results. Women in general are more aware of
their nutrition, have better nutrition knowledge, and eat
healthier than men [35].
With regard to alcohol drinking behavior, additional
studies verify our findings. A higher and more frequent
consumption of alcohol among male students in gen-
eral has been previously reported [36–38]. It seems as if
being young, male and experiencing stress while study-
ing at universities are risk factors that are reliably linked
to unhealthy behavior such as alcohol abuse.
Gender differences should be considered by health
prevention educators and insurances when planning
educational interventions to promote students' healthy
lifestyle [34]. Special health prevention programs should
be developed only for male or female students depend-
ing on their needs and state of health consciousness.
Associations between burnout and relaxing/coping
activities
Significant associations between burnout subdimen-
sions and various coping strategies and relaxing activi-
ties were found. These results indicate that students who
reported performing “healthy relaxing activities after
a day of studying” frequently such as meeting friends,
doing exercises, etc. scored less on EE and DP. Students,
in contrast, who reported a frequent use of harmful
activities for relaxation such as taking drugs, etc. scored
higher on DP.
Few studies also showed that doing exercises, yoga,
wellness, etc. are helpful activities to prevent stress-
related diseases such as burnout. Previous studies, in
contrast, illustrated that taking drugs, drinking a lot of
alcohol, etc. are often used in cases of stress and burnout
as destructive coping strategies [39–41].
Future studies should investigate possible influencing
factors. It would also be interesting if personal character-
istics have an influence on the usage of sedatives, drug
abuse, and coping strategies in general. We found no
study that focused on relations or causal effects between
using sedatives and EE or DP. Study results, however,
illustrate relations between taking sedatives and mental
disorders such as depression and anxiety [42].
Limitations
This study faced several methodological limitations that
should be mentioned in reviewing our findings. First, the
use of this study method may reduce the response rate, as
dental students were requested to complete a web-based
13 Prevention of study-related stress symptoms: health-promoting behavior among dental students   105
original article
survey distributed to them at home. Maybe we would
have reached a higher response rate if we distributed the
questionnaires as a paper-and-pencil version. Second,
the use of a cross-sectional design provided only a snap-
shot of the actual situation. Longitudinal studies are thus
recommended to verify our results. Third, all data regard-
ing coping and relaxation activities, burnout symptoms,
etc. were collected by self-report, posing the risk of unreli-
able data. Finally, the results cannot be generalized to all
dental students. Subsequent research studies with larger
samples are strongly needed to investigate other parts of
Germany, Europe, etc. with more dental students.
Conclusion
In this study, we describe the coping activities of 239 Ger-
man dental students and their scores in the MBI. Nearly
40 % of students suffer from EE. The more frequent use
of healthy coping activities may help to reduce study-
related stress. Our findings indicate the need for relevant
health promotion and may aid decision makers in devel-
oping health promotion programs.
In sum, these study results are to (1) increase sensi-
tivity for psychological strain during medical education,
(2) rise awareness of the complex topic “burnout preven-
tion” among dental students, their educators, and other
researchers, and (3) contribute to the development of
specific prevention strategies for dental students. More-
over, the information generated by our study provides
evidence about the presence of health promotion activi-
ties in dental education in a salutogenic manner.
Conflict of interest 
The authors declare that there are no actual or potential
conflicts of interest in relation to this article.
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