Study on the possible cause of Suicide in the dental profession;

INTRODUCTION

Whereas in the United States, in the general population, suicide occurs in 10.8 per 100.000 persons, there is data – Blachy et al. (1963) – that establishes the occurrence among dentists ranging somewhere between 50 to 64 per 100.000.

Dentistry is a profession with a high incidence of suicide. The most recent report from the CDC on “occupations with the highest suicide rates” came out in 2012 and stated that farmers, fishermen, and forestry workers were at the highest risk of taking their own lives.

In that report, medical professions were at the bottom 12th position which is not too bad. However, the same organism’s National Occupational Mortality Surveillance showed that dentists were 2,5 times as likely to die by suicide than the general population. An online survey was administered to British Dental Association members and nonmembers. Valid responses were received from 2053 respondents. Dentists working in the UK exhibit high levels of stress and burnout and low well-being. General dental practitioners seem to be particularly affected. Issues relating to regulation and fear of litigation were deemed to be the most stressful aspects of being a dentist. These aspects are also present in the United States.

Dr. Steven Stack, a professor of criminal justice at Wayne University, has also extensively researched the correlation between these two elements. The results of his study have proven again that the link between dentistry and suicide is not spurious. Nevertheless, he has looked at sociodemographic factors such as their higher rate of divorce, as added stressors. Our goal here is to establish a closer link between the event and how the characteristics of the profession itself, in the technical surgical, as well as the practice management aspects, can shape the behavior of the dentist. This unbalance can potentially induce suicide when the willpower is depleted. Then, a not so dramatic situation or event can bring about a disproportionate extreme reaction. Let’s analyze the possible occupational stressors that can help us validate this hypothesis.

First, their training. There are different reasons why one would become a dentist, not only in the United States but also in Europe. First and foremost, it can be vocational. Choosing that career path can be the fulfillment of a dream, and for our analysis, this is the best case scenario.

One might also become a dentist, not by intent, but due to lower grade achievement even though, not in all countries the grade required to become a physician is higher than to become a dentist. Hence, the doctor, whose wish was to be an MD, is already starting with a source of frustration and comparison. It may not always be present but could surface when professional challenges arise. Another element is that dentistry is not an easy academic path and continuing education brings on more challenges to that initial choice. Dr. Gordon Christensen, a well-known worldwide researcher in the dental field, compartmentalizes dentistry in the following way:

he considers the profession to be the largest specialty in medicine involving, in the United States, seven subspecialties. A dentist has to show competency in what he calls “the parent specialty, dentistry” but also in all of the subspecialties. Then, the specialist can develop specific skills in the branch he chooses. In most European countries specialties do not exist as such, and therefore 100% of practitioners have to master ideally with excellence all branches of dentistry. This requirement is massive from a theoretical and technical perspective and puts a great deal of pressure on the general practitioner. The general public ignores this and sees, more often than not dentists as the doctor who was not good enough to become an MD or as the professional who is in it for the money This bad reputation sooner or later, takes a toll on the mindset he carries to work every day.

Let’s now take into account additional sources of occupational stress, and anxiety sometimes overlooked.

The first one is Fear.

If we take into consideration that surgery is a specialty “using operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas,” -Wikipedia.org (2019)- even a simple filling becomes a surgical act.

This is why the dentist is called a dental surgeon.

Nevertheless, there is a significant difference with general surgery. Dental surgery is more often than not conducted on a locally anesthetized fully conscious patient. Thus, two significant causes of stress are present throughout the day of a dentist: Fear and anxiety.

One would think that only the patient should experience fear, but it is not so.Why would a knowledgeable professional be fearful of performing what he was specifically trained to do? Because the patient is only locally anesthetized and is always afraid consciously or unconsciously of the drill, the scalpel, the forceps or whatever instrument is being used. That fear can make him or her, react and move unexpectedly which becomes dangerous when the doctor is using either one of those instruments. This is an aspect that puts more strain on a dentist’s daily practice as it may compromise the quality of the treatment and sometimes put the patient’s life at risk during what could be considered a minor treatment. Of course, with experience, mastery dominates and fear is reduced, but in the meantime, the wear and tear of the emotion have already depleted part of the willpower as defined by Roy Baumeister. We will return in detail to this point later The second one is related to the neuroplastic consequences of the type of work the dentist does repetitively for more than 30 years. The art of dentistry implies theoretical knowledge, manual and psychological skills beyond many professions. It requires the level of focus of a surgeon, for as many hours as he is with patients. Let us remind here again as a comparison, that medical surgeons do not operate daily for 10 hours a day, five days a week, just like a pilot does not work more than 14 days a month. Due to financial demands, and the size of his investment, the dentist does that work for more than 8 hours a day, five days a week in most of the cases. Two aspects meet here.

As everything the dentist does has to be precise to the millimeter and even to the micron, there is a dimensional factor. The consequences of an error can be: damaging a tooth irreversibly, failing at the desired aesthetic outcome, or putting in danger the life of a patient. We can easily picture how striving for technical perfection, hour after hour, day after day, year after year in such a profession, can modify the structure of the brain and generate certain levels of neurosis. Therefore it is not only about the direct, immediate stress of the situation, but also about the long-term consequences of the act itself.

The second aspect is temporal. It is related to the aggravation of falling behind schedule, and the effect this will have on the practice flow as well as patient behavior.

These two aspects are well documented by O’Shea – O’Shea et al. (1984) even though they don’t mention the link with the neuroplastic consequences of such a detail-oriented profession and the behavioral changes they can have.

Moreover, a survey conducted by Michaelis in 1984 on 274 German dentists, found how dealing with constant demands of compassion, understanding, and emotional control, led many of the dentists to a feeling of exhaustion very well described under similar circumstances by Baumeister and Tierney in their book Willpower (Penguin Press 2011).

Let us not forget the effect that is causing pain or anxiety to others – patients – on one’s subconscious sense of self-esteem, as mentioned studies by Di Matteo et al. (1993) and Cooper et al. ( 1978).

Pain is an element the patient might have before he goes to the dentist, during treatment, or even after leaving the practice. Therefore in most cases, the dentist is associated in the general population with a painful experience, and that is one more heavy burden to carry when you are a professional striving for excellence. The vibration of the word “dentist” carries based on the person’s perception can be a source of grievance and determine the doctor’s propensity to feel anxious or depressed over the years. Last but not least, as stated by Steven Stack in 1996 in Suicide risk among dentists, the way dental surgeons usually practice can be a significant source of added strain. The dentist is more often than not a solitary persona. Even when practicing in group settings, the moment he treats a patient, he finds himself alone facing whatever decisions arise and once again we know how decision-making can wear down the willpower capital.

Economic pressure is also high due to the challenges of running a small to medium business, often alone, and without the proper training. The investment required to build a dental office can well be over half a million dollars and running it also implies significant overhead in personnel, rent, maintenance, and other running costs, as well as continuing education. If we add to this, eventual student loans, the weight on the shoulders of a single person can be overwhelming. The work hours and constant decision making become insane. To finish listing elements, we can mention the noise pollution in the dental practice whether it be the drill, the suction unit or the compressor, and the consequences it can entail.

Conclusions

“The “In Memoriam” section of Volume 10 of the 1911 American Dental Journal lists ten  dentists who passed away that year. Three of them died by suicide, one from “nervous  collapse due to overwork,” and one reportedly “accidentally shot himself while cleaning  a revolver.” While one century-old obituary page certainly can’t offer a definitive view on  the topic, it’s curious. Of the ten dentists I interviewed for this article, eight of them knew someone from their profession who had died by suicide.”– Elizabeth Brown (2017) – This is not a 21st -century problem caused by factors external to the clinical practice, such as sociodemographic elements like gender or divorce as Steven Stack claims supported by the fact that 99% of dentists are divorced. But Stack, in his 1996 study also shows that being a dentist increased one’s risk of suicide by an extraordinary 564 percent.

This is indeed a situation created by intrinsic aspects that were already present in the 1900s and will be in the future. Dealing with patients in a situation of fear, physical pain, and surrender; dealing with technical aspects such as extreme precision, aesthetic and comfort expectations from patients often beyond normal ; dealing with challenging business and economic aspects without having the related training; dealing with repetitive decision making; adapting to 15 to 20 different patient temperaments in a day trying to have a pleasing personality with all of them… So many aspects that can deplete a person’s willpower.

What is the solution if the profession is what it is? Finding ways to refill the willpower bank before it is too late.

But can willpower be strengthened? As per Baumeister’s studies, exercising self-control in one area improves all areas of life. It seems complicated and even unfair to request

from a professional whose work life is already entirely driven by rigidity and discipline, to bring self-control to other aspects of his life. The moment self -control has become a habit as it does in the professional environment with time, it is not being exercised anymore.

Hence it should be a permanent “getting out of your comfort zone.” Eat with your left hand if you are a righty, do physical workouts, if you run on your own start running in popular races and so on.

However, we see another option. What if on top of strengthening willpower we could control the level of depletion situations cause through meditation. We know how this practice can create new neural pathways and dissolve others – Joe Dispenza, James Austin, William Bodri –reshaping the brain just like the professional repetitive habit did.

Meditation also teaches the mind to rest, become responsive instead of reactive, to put distance between daily situations and oneself. It is our purpose, to develop further this thesis and bring meditation to the dental profession as a tool to gain perspective, balance, peace and wellbeing to a field with an energetic negative overload that no human being should have to tolerate, and in fact, many don’t.