Dentistry is a stressful, life-long profession. Stress usually arises from an imbalance between personal capabilities and external pressures, and this “product of imbalance” is known to lead to burnout in dentistry students, negatively impacting their mental and physical health (Sikka et al., 2021; Tahir et al., 2021). Dental students are known to experience considerable stress (Elani et al., 2014), which not only impairs health but also productivity. Therefore, a comprehensive knowledge of stressors and how they are perceived is essential to mitigate against workplace-based stress, improve health and wellbeing and, in the clinical context, outcomes for patients (Sikka et al., 2021; Tahir et al., 2021).

Several factors predispose dental students to significant levels of stress (Montero-Marin et al., 2014; Salahuddin, 2023). Dental students may be more vulnerable to stress than students in other health professions due to the technical nature of dental procedures, the small margin for error, and limited time available to carry out and complete planned treatments (Demirci et al., 2021; Rayyan et al., 2022; Sattar et al., 2022). Dental studies also have a clinical component that may involve managing challenging patients, heavy workloads (Hayes et al., 2017), and relatively little downtime. For undergraduate dental students, it is known that clinical expertise significantly affects perceived stress (Jowkar et al., 2020). Stress can develop as a result of having too many assignments or exams, competition with other students, a pressure to excel academically, “failure fear” (Narwal et al., 2021), a lack of good relationships with classmates or teachers, personal or financial issues, or exam phobia. Specific subdisciplines may also have specific stressors; for example, the type of fixed prosthodontics procedure being performed has been reported to significantly affect the perceived stress level, with vital tooth preparation and post-space preparation the highest stress-provoking procedures for undergraduate senior students (Rayyan et al., 2022).

Generally, dental students experience higher levels of psychological stress than medical students (Wali et al., 2021). Specific dental education-related stressors include the possibility of not completing course clinical requirements, examinations and grading, the amount of assigned coursework, time limitations, a need to complete preclinical and clinical training, and dental lab cooperation (Meira et al., 2023). Undergraduate dental course requirements, such as the availability of patients and laboratory-related factors, are also significant stressors (Al Sweleh et al., 2017). Furthermore, the development of stress may be influenced by intrinsic factors; for example, gender may play a role as a stress predictor in dental students, with female students showing increased levels of perceived stress than male dental students (Demirci et al., 2021; Meira et al., 2023; Muniz et al., 2022). Other potential non-educational mediators of stress include marital status, with married postgraduate dental students experiencing higher levels of stress than their non-married counterparts (Ghafoor et al., 2020).

Globally, while academic factors like examinations, grading, and workload are often cited as significant stressors (Tahir et al., 2021; Elani et al., 2014; Hayes et al., 2017; Jowkar et al., 2020; Narwal et al., 2021; Wali et al., 2021; Al-Samadani and Al-Dharrab, 2013; Kumar et al., 2009), there are also geographic differences. In Western countries, finance-related stress (i.e., debt) is a dominant stressor (Hayes et al., 2017; Wali et al., 2021). In a study from the UK, elevated levels of stress were associated with poor coping mechanisms (Narwal et al., 2021). Dental students in Africa reported stress related to resource and material availability (Wali et al., 2021), while Turkish and Iranian dental students were stressed by academic factors, which were related to the year of study (Demirci et al., 2021; Jowkar et al., 2020). Indian dental students experienced stress due to parental pressure (Alzahem et al., 2011). In the Saudi Arabian context, Rayyan et al. reported significant stress in dental students performing fixed prosthodontic procedures related to vital teeth and post-space preparation (Rayyan et al., 2022), and patient and equipment availability, together with lab support, also influenced the amount of perceived stress in dental students in Saudi Arabia (Al Sweleh et al., 2017). However, while most previous studies have focused on students’ stress experience, fewer studies have explored related coping mechanisms and their effectiveness in reducing the negative effects (Sikka et al., 2021; Narwal et al., 2021). Most of the existing literature is single-center and observational and did not measure changes in stress over time nor biomarkers of stress (Alzahem et al., 2011).

Saudi Arabia is a diverse country representing a variety of sociocultural origins (Alzahem et al., 2011). This social and cultural diversity may influence perceived stress caused by different stressors, and, as a result, the causes and consequences of stress in dental students in Saudi Arabia may be different to other countries or between different regions within the country. While there have been many global studies of stress levels and risk factors in undergraduate dental students, including in Saudi Arabia, no study on this topic has yet been conducted in Saudi Arabian postgraduate dental students. Therefore, the first aim of this study was to investigate the level of self-perceived stress and determine possible stressors in postgraduate students attending the Prosthodontic Department at King Abdulaziz University, Jeddah, Saudi Arabia. The second aim of the study was to explore whether perceived stress was influenced by gender, year of study, and presence and duration of previous qualifications. The overall goal of the study is to provide administrators and academic staff with country-specific strategies to address student stress (Al-Samadani and Al-Dharrab, 2013). The study had two null hypotheses: (1) first, that postgraduate prosthodontic students experience no psychological distress; and (2) there is no association between gender, level of study, and previous qualifications and their stress experience. Consequently, the study questions were: (i) what are the burden and main causes of perceived stress in postgraduate students in Saudi Arabia, and (ii) do gender, level of study, and previous experiences affect their stress experience?

This was a pilot study exploring the common causes of stress in postgraduate students and reflected on their perception and understanding of the stress phenomenon in terms of people’s lived experiences. This small-scale, exploratory, cross-sectional study was designed to examine methodologies for future use in larger-scale studies exploiting the increasing number of postgraduate dental students across Saudi Arabia and identify challenges and barriers to participant recruitment when exploring common causes of stress.

The Faculty of Dentistry at King Abdul-Aziz University’s Research Ethics Committee authorized the study (no. 069-03-23). We distributed an online survey to 35 postgraduate dental students enrolled in the Master’s (M) and Board (B) programs at the Department of Prosthodontics, King Abdul Aziz University, Jeddah. Participants were at different stages of study: first year (M1, B1), second year (M2, B2), and third year (M3, B3).

This study aimed to determine perceived sources of stress and the need for positive coping mechanisms in postgraduate clinical residents in the Department of Prosthodontics at King Abdul-Aziz University to establish whether specific personal factors might influence how stress sources are perceived. Identifying the most important stressors would allow for targeted implementation of stress management strategies, such changing the curriculum or providing a more supportive atmosphere through a more proactive approach.

Previous studies have shown that postgraduate clinical residents are more stressed than undergraduate dentistry students (Azmimurad, 2019). Our results seem to be consistent with this and reject our null hypothesis, with the results indicating that stress is a problem for all postgraduate dental students, who experienced significant levels of emotional stress throughout the first year (M1, B1), second year (M2, B2), and third year (M3, B3) due to the prevalence of stress. Another study conducted in Jordan demonstrated an increase in stress over time and year of study (Abu-Ghazaleh et al., 2016), while clinical performance pressure provoked the highest stress level in undergraduate students (Lin et al., 2020).

The first significant cause of severe stress among dental students was academic overload (62.9%), followed by fear of failure (51.4%), completing examination requirements, and difficulty in finding suitable patients (48.6% each). These results are consistent with previous studies reporting that academic circumstances contribute to stressful experiences in dental students (Tahir et al., 2021; Elani et al., 2014; Hayes et al., 2017; Jowkar et al., 2020; Narwal et al., 2021; Wali et al., 2021; Al-Samadani and Al-Dharrab, 2013). Our pilot study indicates that postgraduate students are subjected to considerable psychological stress. Prosthodontics residents at King Abdulaziz University must finish several courses during their years of study and pass exams. The curriculum involves general dentistry and specialty courses, each of which has its own requirements and assignments. Frequent presentations, lab work, exams, and assignments are all assessed. Also, the program requires students to complete a certain number of cases of variable complexity to be eligible to sit the final exams. While this intensive course may contribute to elevated stress levels, this must be balanced against maintaining high clinical standards and the development of appropriate competencies.

Senior postgraduate clinical residents often experience high stress, and research demonstrating that coursework difficulty increases over time (Azmimurad, 2019). A study conducted in the UK reported increased stress levels as the academic course proceeded (Collin et al., 2020). The most significant stressor, according to year three postgraduate clinical residents, was academic overload (85.7%), followed by fear of failure (71.4%) and completing examination requirements (71.4%), with the curricular components contributing most to their increased stress levels. Too much work to be done in insufficient time (71.4%), stressful academic activities, and staff criticism of academic and clinical performance are all known to contribute to elevated stress in students due to a greater sense of fear of failure (71.4%). Other contributory factors to final year stress may have included only limited time available to complete clinical requirements, which often requires high standards of lab performance to decrease the risk of needing to remake the prosthesis, thereby delaying case completion. Also, our students must complete department presentations on the final treatment results, which demands a successful treatment outcome and evidence-based treatment approach that can lead to an escalating sense of responsibility and anxiety. Indeed, Azmimurad (2019) reported that prosthodontics courses caused students the most stress, with periodontology the least stressful course, again due to curriculum-related concerns like excessive workloads, inadequate time, and the pressure of academic activities (Azmimurad, 2019).

Postgraduate dental training involves many continuous tests and exams that might increase stress levels (Sikka et al., 2021; Tahir et al., 2021; Salahuddin, 2023; Meira et al., 2023). The limited time available to complete the required work, taking exams, and preparing for the final semester exam could all contribute to academic overload. We similarly found that students are anxious about exams and grades (40.0%) and their ability to meet exam criteria (48.6%). Students reported having to do too many tasks quickly, which left them with no time for social activities. Exam and grade pressure and failure-related anxiety both reflect academic overload, which is not easy to resolve quickly, and are consistent with known stressors such as performance anxiety and failure dread (Al-Samadani and Al-Dharrab, 2013; Kumar et al., 2009).

We did not detect any gender-based differences in our leading stressors, including academic overload and fear of failure. The existing literature on stress and gender imbalance varies. Some researchers have similarly reported no gender differences in regard to perceived dental stress (Muirhead and Locker, 2008; Sofola and Jeboda, 2006), but Kumar et al. (2009) reported that male students experienced higher levels of stress than females. Other studies have also reported a female predominance of stress, perhaps related to cyclic hormonal fluctuations (Sikka et al., 2021; Demirci et al., 2021; Jowkar et al., 2020; Muniz et al., 2022). In Saudi Arabia, there has recently been some equity in employment in men and women, so both genders are now generally subjected to the same work environment stressors, which may explain the similarities seen here. Overall, and within the limitations of the study, the data support the null hypothesis that there is no association between perceived stress and gender.

Allocating suitable patients for treatment in postgraduate clinics (48.6%) created a significant issue with respect to being able to complete clinical work and requirements on time, similar to earlier studies (Wali et al., 2021; Al Sweleh et al., 2017). A lack of available patients is problematic for students, who have limited time to complete their requirements for final exam entry, which may contribute to significant stress. Clinical students must find suitable patients to complete their clinical requirements, a serious issue that may be resolved with proper patient screening and departmental referrals (Wali et al., 2021). Our unit attempts to proactively solve this issue: prosthodontic screening clinics are scheduled frequently for proper patient selection and introduction to prosthodontic treatment to enhance compliance and cooperation. Also, any history of appointment cancelations is electronically recorded and monitored to evaluate cooperation. However, despite these institutional actions, patient availability remains a problem for dental students, and other interventions, such as public dental health awareness campaigns and patient recruitment programs, are required.

Our results confirm that dentistry is a physically and mentally demanding profession with stringent work schedules that place dentists with the responsibility to maintain their health for patient wellbeing. Improving housing and infrastructure, access to dental materials, and help from the prosthodontics lab to complete restorations have been proposed as a stress-reducing solutions (Cocchiara et al., 2019). Other solutions include limiting the number of patient and school interactions, ensuring availability of qualified student counselors, and providing targeted programs for dentistry students to manage their stress and self-care (Sharma, 2013). Dental students could practice relaxation techniques like yoga and meditation to better manage stress (Gosavi et al., 2012; Peleias et al., 2017), and courses in oratory, psychology, and financial business management could help reduce stress through education and knowledge. Young dentists might benefit from the knowledge and experience gained from specialized courses in patient communication, developing self-confidence, and handling difficult circumstances (Alzahem et al., 2014). Regularly holding such workshops could help reduce stress in dental professionals and improve clinical competency (Antanaviciene et al., 2020). Our new data support our previous findings in undergraduates, where stress could be related to the same circumstances within the same academic environment (Al-Samadani and Al-Dharrab, 2013). While we did not detect an association between year of study and stress, in contrast to undergraduate students, our results should be interpreted with caution for the relatively small sample size due to single-center design where the available number of postgraduate prosthodontic students was limited and this may be due to the newly established program.

With respect to education-related stress factors, adequate preclinical training has been reported as the main factor in reducing psychosocial stress in dental students (Alzahem et al., 2014). Academic institutions should provide adequate planning, implementation, and enforcement of preclinical training to improve clinical skills and increase student confidence (Rayyan et al., 2022; Haralur and Al-Malki, 2014). This should be accompanied with proper academic support and service visibility, especially during transitional phases of study (start of dental clinics) (Alzahem et al., 2011; Haralur and Al-Malki, 2014). It would be helpful to implement a curriculum revision and development committee within dental schools to update curricula and establish a positive academic environment (Divaris et al., 2008). Moreover, dental colleges should provide adequate lab support for clinical students by employing well-trained technicians, together with regular professional development courses for dental technicians, such as in the application of CAD/CAM and printing technologies, to improve accuracy and reduce student burden. Providing a relaxed environment for feedback meetings and incorporation of extracurricular activities within a timetable might be helpful, supported by courses in time management and life skills, stress management, and coping skills, especially for junior students and students transitioning to clinical work. Incorporation of mental assessments into selection and enrollment processes, together with periodic assessments of stress and stressors and positive coping strategies, are essential (Alzahem et al., 2011). Furthermore, support groups and mentor guidance are essential components of a holistic approach to tackling student stress.

The creation of a positive but safe academic environment must be accompanied by cultivation of ethical and cultural values that boost personal and professional growth (Divaris et al., 2008). Strategies could include provision of on-campus recreational activities and facilities and a clear strategy for assessment and early detection of stress symptoms, together with robust management plans (Alzahem et al., 2011). Flow chart guidelines could represent an innovative approach to help staff identify symptoms of stress such as avoidance, fatigue, weight loss, sleeplessness, and irritability (Rayyan et al., 2022; Sattar et al., 2022; Alzahem et al., 2011; Divaris et al., 2008). Staff training could include workshops that improve awareness about stress and short training courses on relaxation and stress management to help both staff and students (Sattar et al., 2022; Alzahem et al., 2011; Steiner-Hofbauer and Holzinger, 2020). Furthermore, recognition and comprehension of personal and other emotions and regulation of feeling, actions, and behavior toward challenging circumstances is termed emotional intelligence (EI) (Jahan et al., 2022; Mayer et al., 2016; Por et al., 2011). Students with EI show better regulation of emotions and self-control that translates into better stress coping mechanisms, patient communication, and consequently improved patient compliance and satisfaction (Jahan et al., 2022). Therefore, staff and students may benefit from EI training courses by development and enhancement of this skill. Other possibilities for overcoming stress within the institution include cultivation of resiliency, which is the ability to adapt and to recover from emotional and psychological distress (El-Ashry et al., 2023; Ghoneam et al., 2025). To prevent burnout and preserve empathy, measures could be taken to assess for compassion fatigue (El-Ashry et al., 2023). However, such initiatives will need to be adequately resourced, placing strains on institutional budgets, as each requires appropriate training, counseling service support when help is needed, and fit-for purpose environments, including practical measures like flexible clinical booking and scheduling when needed with easy accessibility for mental health resources and counseling.

Stress experienced at dental school may contribute to future professional life burnout (Muirhead and Locker, 2007). We found that the main stressors were academic factors, which may help to guide future recommendations for institutional action plans. However, other unmeasured factors may influence the stress perceived by dentists. For example, students living with parents may benefit from family financial and psychological support, although one study reported higher stress in these students (Muirhead and Locker, 2007), so further clarification of the association is required. The availability of on-campus entertainment and sport facilities may influence perceived levels of stress (Alzahem et al., 2011). Furthermore, personal factors such as pre-existing mental health problems, financial constraints, family issues, personal beliefs and traits, language barriers, time management issues, and low EI could contribute to an increased level of stress in dental students (Alzahem et al., 2011). As dental programs are one of the most expensive courses, placing additional burden and stress on self-funded dental students (Muirhead and Locker, 2007), government support for these programs should be considered to lower personal debt burdens, reduce the need for part-time work, and restore work- life balance (Alzahem et al., 2011; Divaris et al., 2008).

Here we investigated the level of self-perceived stress and possible stressors in postgraduate students attending a dental school in Saudi Arabia to pave the way for definitive, multi-center studies. Within the limitations of the small-scale exploratory design, postgraduate dental students at King Abdul-Aziz University School of Dentistry may experience significant levels of stress. However, due to the limitations of this study, the findings can be considered as preliminary and must be cautiously interpreted. Although it establishes feasibility, it warrants further larger-scale, multi-center and comparative studies in the Middle East and beyond for future planning of stress management strategies for dental students and graduates. In addition, it is recommended to plan for periodic stress assessment research and future powering to guide further larger-scale studies. Future studies should include a larger, longitudinal study and mixed-methods approaches that incorporate not only objective assessment tools but focus groups and interviews to provide more details on the underlying psychological processes related to stress to guide specific interventions.