Dentists’ Mental Health: Challenges, Supports, and Promising Practices

Abstract

Objectives:

The mental health of dentists, like all health professionals, is a growing concern. The objectives of this study were to identify the mental health challenges experienced by Canadian dentists and to describe the support needs and promising practices to better support them.

Methods:

This study used a mixed-methods case study design to gather data from semistructured qualitative interviews and a survey for triangulation.

Results:

Thirty-six dentists and 17 stakeholders participated in the interviews, and 397 dentists participated in the survey. The interview and survey data revealed that dentists have experienced several challenges personally, professionally, and socially. Around 44% of participating dentists experienced a wide range of mental health issues, including depression, anxiety, and posttraumatic stress disorder. Sex/gender shaped the mental health experiences of female dentists, who reported more stress related to caring responsibilities. They had a higher percentage of mental health issues (50%) than men (37%). Caretaking emerged as the main challenge in the social and personal domain, particularly for female dentists in both survey and interview findings. The dentists’ role in practice was one of the most frequently reported professional challenges. While practice owners reported challenges with staff and practice management, associate dentists experienced difficulties with the lack of autonomy and conflicts with office managers and owners. Other challenges reported by participating dentists included patient care responsibilities, loneliness, and isolation. To address these challenges and their impact, dentists and stakeholders identified several support needs and promising practices, including increasing awareness about mental health issues, expanding existing mental health resources, incorporating mental health content in dental education, and encouraging engagement in organized dentistry, particularly for women.

Conclusions:

The impact of mental health challenges on dentists’ career trajectory and productivity is an ongoing concern in Canada. Gender-specific strategies to support the mental health of dentists should be developed.

Knowledge Translation Statement:

This study identified the mental health challenges of dentists in Canada to inform the development of interventions and strategies to promote the health and well-being of dentists and dental students. It also highlighted the need for clinicians, students, and individuals in leadership positions in institutions and professional organizations to recognize and consider the working conditions of dentists in various positions to avoid negative consequences on their mental health, reduce the attrition from the professional, and improve patient care outcomes.

Introduction

The mental health of dentists, like all health professionals, is a growing concern (Lang-Runtz 1984; de Ruijter et al. 2015). Mental health challenges reported by dentists include stress (Song et al. 2017; Collin et al. 2019), burnout (Huri et al. 2016; Song et al. 2017), anxiety and depression (Song et al. 2017; Collin et al. 2019), addiction and substance use disorders (Pilgrim et al. 2017), suicidal ideation, and suicidal attempts (Hopcraft et al. 2023; Zimmermann et al. 2023).

Well-being and mental health are multifaceted and complex, warranting attention to the various factors that contribute to the development of mental health issues. Previous research has linked dentists’ mental health challenges to work-related factors, including job demands and work environment (Bretherton et al. 2016; Pouradeli et al. 2016; Singh et al. 2016; Pilgrim et al. 2017; Prasad et al. 2017; Salazar et al. 2019; Toon et al. 2019; Hopcraft et al. 2023). In a longitudinal study of Finnish dentists, the workload, work responsibilities, and the physical work environment were predictors of burnout over the course of 3 years (Hakanen et al. 2008). Moreover, in a recent study that explored the role of the work organization in shaping dentists’ health and well-being, Gallagher et al. (2021) found that workplace culture, financial concerns, and lack of time decreased dentists’ satisfaction, and perceived control over their professional roles impacted their mental health and well-being.

Sex/gender and age have also emerged as important intersecting factors that shape dentists’ well-being and mental health. In some studies, female dentists were more likely to report and experience mental health issues than male dentists (Pilgrim et al. 2017; Meira et al. 2020). Conversely, other studies examining burnout in dentists have shown no gender differences (Chohan et al. 2020) or an increased prevalence of burnout among male dentists (Singh et al. 2016). Similarly, evidence around the role of the dentists’ age and experience seems to be conflicting. A large number of studies report that younger dentists were at higher risk of developing mental health issues, particularly burnout, compared to senior practitioners (Singh et al. 2016; Molina-Hernández et al. 2021; Noori et al. 2022). Other studies, however, reported no association between age and mental health issues (Chohan et al. 2020) or a negative correlation between years of experience and the dentists’ well-being and life satisfaction (Lee et al. 2019).

Although informative, the conflicting information offered by these studies highlights empirical and knowledge gaps. Empirically, the majority rely on cross-sectional and descriptive quantitative designs, which may fall short in providing an in-depth understanding of the complex challenges that dentists encounter and often contribute to deteriorating mental health issues (de Ruijter et al. 2015). This understanding requires expanding the current body of knowledge beyond the role of the work environment and content to comprehensively study the life circumstances and social and structural challenges experienced by dentists, potentially impacting their mental health (Toon et al. 2019). For instance, gender and ethnic origin (which have been predictor or independent variables in quantitative studies) are multifaceted social constructs that should be examined in the context of the dentists’ lived experiences to allow for a well-rounded understanding of the factors that shape the dentists’ mental health and well-being.

In terms of the knowledge gap, a paucity of studies offer insights into the changes and actions required to alleviate dentists’ stress and maintain their mental health and well-being (Yansane et al. 2021; Geisinger and Dershewitz 2022). Several studies highlighted the need to move away from the deficit approach and involve dentists in developing solutions and professional practices to promote their own mental health and well-being (Gallagher et al. 2021; Plessas et al. 2022). Therefore, this study’s aims were two-fold: to identify the mental health issues experienced by Canadian dentists and their causes and to describe the support needs, recommendations, and promising practices to better support dentists’ mental health and well-being.

Methods

Study Design

This study is a part of a larger inquiry that examined the mental health and leaves of absence and return to work of 6 professional groups, including academics, teachers, accountants, physicians, nurses, midwives, and dentists (Ferguson et al. 2022). A mixed-methods case study design was used, drawing primarily on individual semistructured interviews with Canadian dentists and stakeholders (e.g., executives in regulatory bodies, dental associations, insurance organizations), complemented by a bilingual online survey data to achieve triangulation and, consequently, enhance the study’s rigor and credibility (Mathison 1988). The case study design was chosen due to its flexibility in capturing dynamic and complex phenomena, such as mental health and well-being. Case studies encourage researchers to use multiple data sources to provide a more holistic description of the phenomena of interest (Merriam 1988; Gates and Schwandt 2018). The study began with stakeholder interviews, followed by survey data collection and interviews with dental practitioners. Both the interviews and survey were conducted and available in either English or French, and they were informed by a rigorous scoping review that included scientific and gray literature and conducted by the research team members (J.A., T.M., and S.R.) in the early stages of the study. Ethics board approval for the overall project was received by the University of Ottawa and 16 other participating universities from team members across Canada.

Participants

Dentists’ and stakeholders’ recruitment from across Canada took place between December 2019 and June 2021 using purposeful sampling (inclusive of snowball sampling) (Suri 2011; Patton 2014). Participants were recruited using social media platforms and email invitations to dentists listed in the registry of Canadian associations and organizations and direct emails to stakeholders. Recruitment for interviews continued as part of the survey recruitment as well, where survey invitations sent electronically to participants starting November 2020 have included both the survey link and an invitation to participate in semistructured interviews. Dentists who did not wish to complete the survey but wanted to participate in the interviews were asked to directly email the research team to obtain their consent and schedule interviews.

Data Collection

The interviews were conducted in a sequential manner by a senior research associate (J.A.) and graduate students (T.M. and S.R. ) and continued until saturation was achieved (i.e., when no new findings emerged). The interviewing team consisted of experts and trainees who have received formal training in qualitative interviewing. Three team members were dental professionals. Additionally, all team members were involved in mental health research in the population of practicing dentists and dental students. The interview guide consisted of 4 main categories: 1) individual demographics, 2) mental health, 3) leave of absence, and 4) return to work. All interviews were conducted remotely, either via Zoom or over the phone. The interviews’ duration ranged between 30 and 90 minutes. The online survey was designed to provide an overview of the mental health issues experienced by dentists both professionally and personally. The survey also asked dentists about the mental health services they accessed, the challenges they experienced, and the consequences of these challenges, including whether or not participating dentists have taken a leave of absence. The survey was pilot-tested with expert team members as a form of survey face validation and to ensure optimal and smooth structure, wording, and flow. The survey was revised and then pilot-tested again with dentists (n = 3) for validation, and the final survey was available for participating dentists to respond to between November 2020 and April 2021. Of note, only 1 survey question was required, which asked participants to identify their profession. All other questions were optional, and participants were given the choice to skip them should they wish not to disclose certain information.

Data Analysis

Interviews were audio-recorded, transcribed verbatim using Otter.ai, and reviewed for accuracy. Each interviewee dentist and stakeholder were given a code name in order to ensure confidentiality. NVivo software Version 12 was used to thematically code the interviews with dentists (performed by T.M.) and stakeholders (performed by J.A.). The analysis was guided by a preliminary codebook that was developed in collaboration with researchers from other case studies involving the other professions. This deductive phase aimed to achieve the research objectives by capturing the challenges experienced by participating dentists, their impact on their mental health and well-being, and their recommendations to address these challenges. The inductive analysis continued to capture and present themes emerging beyond the codebook and the guiding research objectives.

Survey data analysis was conducted for responses with a completion rate of 90% or higher. Descriptive statistics, including frequency cross-tabulations, were generated, and a test of equality of two- proportions and χ² was used to examine sex/gender differences in mental health challenges with a p-value of less than 0.05.

Results

Thirty-six interviews were conducted with practicing dentists and 17 with stakeholders (Table 1). Seven stakeholders were representatives from dental associations across Canada, 3 from regulatory bodies, 5 from academic institutions, 1 from an insurance organization, and 3 interviewees from other relevant organizations (i.e., organized dentistry groups).

Table 1.

Distribution of Dentists Participating in the Survey and Interviews.

Category	Survey Number	Worker Interviews Number
Gender
Women	194	18
Men	185	18
Black, Indigenous, and people of color (BIPOC)
Yes	39	9
No	27	27
Age
Under 30	24	NA
30–39	76
40–49	76
50–59	100
60–69	73
70 and older	23
Position
Practice owner, partner in a practice	183	18
Associate, employee	115	12
Other (academics, retired, working in public health units)	16	6
Practice setting
Urban	326	28
Rural	24	8

NA, data not available for all participating dentists.

A total of 397 survey responses were received from dentists located across Canada (comprising nearly 1.5% of licensed dentists in Canada).

The results of the participants’ mental health experiences and the impact of work-related challenges and personal and familial challenges are presented first, followed by the support needs, recommendations, and promising practices. These 2 themes are then integrated with the survey data where pertinent to triangulate the findings from the qualitative thematic analysis (Table 2).

Table 2.

Mental Health Issues and Sources of Stress Experienced by Dentists Who Responded to the Survey Stratified by Gender.

Characteristic	Female, % (n)	Male, % (n)
Mental health issues
Mental or psychological stress or distress	31.9 (62)	22.2 (41)
Burnout	24.2 (47)	15.1 (28)
Anxiety	36 (70)	16.2 (30)
Depression	12.4 (24)	3.7 (7)
Substance use/dependence	4.1 (8)	0
Posttraumatic stress disorder	3.6 (7)	0
Sources of stress: work related
Work overload	41.7 (82)	32.4 (60)
Stress of running a practice, managing people, meeting budgets	45.6 (89)	51.3 (95)
Uncertainty	15.4 (30)	11.9 (22)
Poor relations with coworkers/colleagues	13.9 (27)	8.6 (16)
Poor relations with patients/clients	9.3 (18)	6.4 (12)
Ethical dilemmas	6.2 (12)	9.2 (17)
Lack of psychological safety at work, including bullying, harassment, discrimination, or workplace violence	5.7 (11)	0
Sources of stress: nonwork related
Physical health problem or condition	16.5 (32)	14.6 (27)
Debt/financial situation	23.7 (46)	16.7 (31)
Caring for children	29.9 (58)	11.9 (22)
Caring for others (outside of work)	16 (31)	9.2 (17)
Time pressure/not enough time	39.2 (76)	24.9 (46)
Emotional or mental health problems	19 (36)	8 (15)

The percentage was calculated by dividing the number of responding dentists in each category by the number of dentists who have completed the survey in full. Incomplete participation was not included in the percentage calculation.

Dentist Mental Health

Participating dentists described their experience of a wide range of mental health issues, including stress, anxiety, depression, burnout, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and suicidal ideation. Some participating dentists clarified that they received a formal diagnosis of their issues by a mental health professional. Other interviewees self-reported those issues and their experiences without seeking a diagnosis from a professional.

I actually started to feel the effects of burnout. I was forgetting stuff, I was not very happy. I just didn’t like what I was doing at work. And I know I’ve gone through parts of my career where I didn’t quite like it. But I managed. But this . . . I was seriously contemplating giving up practice altogether. (WI-23)

These experiences of participating dentists were also observed by participating stakeholders, who flagged several mental health issues among dentists. From a regulatory standpoint, stakeholders described the drug and alcohol dependence issues experienced by dentists that often followed a patient complaint to the relevant regulatory body. Participating stakeholders shared their experience of the potential repercussions of unresolved and untreated mental health conditions that put the patients’ well-being at risk, including forcing dentists to surrender their license with the purpose of protecting the public. It should be noted that stakeholders emphasized that this option is often a last resort that regulatory bodies may use in cases where dentists may refuse to seek help or use the available resources to support their mental health, potentially jeopardizing the quality of care they provide to the public.

The survey results also corroborated these findings, as the percentage of responding dentists suffering from a mental health issue was 44% (Table 2). A higher percentage of female participating dentists (59%) reported these issues in comparison with male participants (39%).

Work-Related Challenges

Several factors, including the work environment, the demands of the profession, and patient care difficulties, influenced the participating dentists’ experiences of a range of mental health symptoms, including stress, anxiety, and burnout. Furthermore, sex/gender also influenced the dentists’ experience with regard to their professional roles, discussed below where pertinent under each subtheme.

Patient care responsibilities

Participating dentists experienced several challenges in providing care for patients. For instance, some dentists recognized that stress may stem from “patients who are in pain usually or generally scared of seeing dentists” (WI 9) and “challenging kids, challenging patients, the ones that you just seem to dwell on and make you not want to be a dentist anymore” (WI 23).

Further, some aspects of patient management threatened the participating dentists’ mental health. While participating dentists expressed general comfort in terms of clinical treatments and procedures, many brought up the challenges related to “trying to satisfy patients, because sometimes people have unreasonable expectations. If they need a tooth extracted, but don’t want it extracted, there’s nothing you can really do about it. So then they just get frustrated with that sense. And then I can’t please them. So, when I can’t do what they want, or what they think should be done, that’s kind of a battle within myself” (WI-26).

From the perspective of participating dentists, some patient populations were more challenging than others, including elderly patients, patients from marginalized communities in public health units, and incarcerated patients in correctional facilities. They shared how they often internalized their patients’ anxiety, distress, and fear, which impacted their own mental health.

Participating dentists raised ethical practice as one of the prominent mental health issues when treating patients from marginalized communities. In rural and remote areas, where oral health care resources are scarce, patients often relied on government programs to finance their dental treatment. However, the fee schedule for dentists reimbursed under these programs is very limited, which often left them struggling between turning down patients with this coverage, providing them with suboptimal treatment, or risking financial loss.

I find more stress coming from feeling the need to see patients who are on some of these government-supported programs. . . . That stuff gets very, very challenging. If your patients have to travel an hour away to go see somebody else in a larger center, there’s no public transportation. You ethically feel that you have to, and the remuneration there is dismal. And then that starts to take up a good chunk of your day, every day, which is very frustrating. Those are the days I think that you are the most stressed because how are you going to pay the bills? (WI-35)

These findings were in line with those of the survey, with 7.6% of participating dentists reporting struggling with ethical dilemmas (Table 2).

Ethical dilemmas also surfaced while trying to navigate the office managers’ pressures and push for profit-driven procedures and unrealistic targets. Some dentists, particularly women, believed that these targets conflicted with their clinical judgment and posed a threat to their mental health and well-being.

I felt that my reputation was being really jeopardized. . . . I felt really distraught about what was happening. That’s because . . . it’s health care, we’re not selling cars, we’re not in the business of selling jeans, it’s a person’s body. And to me, that’s very sacred. So it was a terrible feeling. (WI-36)

Female dentists shared their experiences of prejudice related to their ability to carry out certain procedures. Several female participants shared incidences where patients perceived them as less capable of carrying out oral surgery procedures, including tooth extractions. As a response, some participating female dentists experienced additional pressure and frustration when they were perceived as less competent, treated differently, or assumed to be the assistant.

Role and responsibilities in the dental practice

Some of the challenges experienced by participating dentists varied according to their role in the dental practice. First, associate dentists shared a lack of autonomy and control over their schedules, which contributed to their stress and negatively impacted their motivation. These participants described their conflicts with office managers and/or owners, who did not seem to “understand the profession, the challenges of the profession, they don’t really care about the staff or health care professionals. They just have no understanding of the demands of a professional or empathy for dentists or staff” (WI-9).

Further, participating associates encountered several incidences where their mental health was strained by what they felt was the micromanagement and bureaucracy in their dental offices. Associate dentists also described the pressure of some office personnel who may set unreasonable and profit-driven goals for the associates to fulfill, which led some of them to experience significant stress and, in some cases, leave the practice altogether. Similarly, 13% of the dentists participating in the survey, whether they were associates or in other roles, experienced stress due to poor relationships with coworkers and other personnel in the dental practice.

In addition to conflicts and frictions with the office staff, some participating associate dentists experienced bullying incidents in their work environment, where the managers displayed “an attitude of being mean, being bullies, and wanting to bully people to do what they want, [and] to maximize profit” (WI-9). ¹ Similarly, the impact on the dentists’ mental health had driven some to change their workplace or their roles. The survey findings that encompass associates and dentists in other roles support this theme, as 5.6% of participating female dentists (associates or in other roles) experienced challenges related to psychological safety at work. On the other hand, none of the participating dentists who identify as men reported experiencing psychological safety issues (Table 2).

Practice owner dentists interviewed discussed how being a practice owner entailed a greater responsibility in terms of managing the practice’s human resources, finances, and productivity. They had additional concerns about competition in the profession, as illustrated by the following quote: “There’s too many dentists. And it’s a very expensive type of practice and type of business to run, your overhead is insane. And 70% is pretty normal in the industry. For every $100 you make, you’re spending $60 to $70 just to keep the place running. And that’s when you’re fully booked. So that’s challenging” (WI-34).

Other practice owners’ duties included troubleshooting and managing any emerging IT issues, in addition to ordering supplies and managing inventory. Participating practice owners spoke about the challenges they experienced with finding and retaining trained and competent dental staff, including dental receptionists, assistants, and hygienists, particularly in rural and remote areas. For many participating practice owners, these responsibilities impacted their perspective about profession, where frustration took away some of their professional satisfaction. This was supported by the survey findings, as 48.5% of participating dentists in various roles reported practice management responsibilities as a work-related stressor (Table 2).

The most challenging for me at work is managing my staff. Since the pandemic, there was a lot of turnovers for about 2 or 3 years. (WI-18)

[Practice ownership] is stressful, because you have to wear many different hats. That’s stressful. You’re not just a health care provider. You’re a business owner. It’s not an easy balance to strike, and the time commitment is incredible. (WI-17)

Sex/gender influenced participating dentists’ mental health experiences and their participation in different professional roles in the dental practice. Several female participating dentists who were practice owners described the challenges with some staff members who perceive female dentists as less assertive, more dramatic, and less productive than male dentists. This, in turn, impacted their staff’s respect and response to feedback given by female dentists in the context of practice management and patient care duties.

When a man says something to the staff they want something a certain way, the staff would feel that he’s the boss and he’s being assertive. Whereas if a woman said the exact same thing, she feels like she doesn’t command as much respect, that that assertiveness can be taken as whiny or bitchy. (WI-11)

Consequently, some female participating dentists felt that they and other females were more stressed than male dentists. Additionally, female dentists discussed how they felt that they needed to suppress their emotions as they “don’t want to seem emotional, [and] want to be strong, [and] find that [they] have to be tough like the men” (WI-16).

Further, these negative mental health experiences contributed to changing the women’s willingness and desire to own a dental practice, as several female dentists mentioned not wanting to own a dental practice. Similarly, many female dentists who owned dental practices had considered selling them and reverting to an associate role to balance personal and professional responsibilities. Of note, the test of equality of two-proportions revealed statistically significant sex/gender differences in 1 work-related category: workload, with more female dentists reporting workload as a work-related stressor in comparison with men (p = 0.048).

Loneliness and isolation

Practice owners and associates struggled with a sense of isolation, as described by a practice owner: “It can be very lonely being a sole proprietor. [Staff members] all turn to you” (WI-17). Of note, the environment of solo and/or rural and remote dental offices seemed to further exacerbate the dentists’ isolation and loneliness.

Associate dentists also described the lack of support in their work environment, with some associates narrating their experiences:

I was on my own, I had no support, I had no other dentists to call upon if I ran [into] any trouble, right in the middle of a procedure, it wasn’t like I could go to the next operatory and ask for help. It was. . . . It was . . . it was a struggle. (WI-26)

Personal and Familial Challenges

Personal and familial factors influenced the mental health and well-being of dentists in the interviews and the survey.

Intersections of age, sex/gender, ethnic origin, and mental health

Younger and newly graduated dentists experienced stressors related to the debt load that they had graduated with, a finding that was echoed in the survey by 20% of participating dentists from different age groups. This stressor was also exacerbated by the uncertainty about job and mentorship prospects. Age also intersected with sex/gender, as younger female dentists who participated in the interviews discussed the numerous physiological changes that they have experienced during pregnancy, perimenopause, and menopause, which all influenced their mental health and well-being.

Another issue that impacted the interviewee dentists’ mental health was race/ethnicity. For instance, participating dentists discussed experiences of the racism that they had encountered or witnessed firsthand, particularly in rural and remote settings with lesser representation of visible minorities. In the case of internationally trained dentists, some interviewees experienced difficulties with community integration, language barriers, and the financial burden of supporting both their immediate and extended families.

Family relations and responsibilities

Caregiving responsibilities impacted the participants’ mental health and well-being. As one noted:

Sometimes it’s not because you’re having a hard time, it’s because it’s a family member. And you need help, because you need to disassociate yourself from that issue. And learn to do that. (WI-35)

Female participating dentists experienced challenges balancing their traditional responsibilities, including running a household, childbearing and childcare, and the numerous responsibilities of owning a dental practice. This conflict and the blurring of home–work boundaries, especially for practice owners, led to a sense of guilt toward children and family members, in addition to feeling overwhelmed and stressed out.

Challenging relationships with family members, including their stigmatization of mental health issues and the lack of support by partners, contributed to many mental health issues from the perspective of interviewee dentists. Female participating dentists in particular struggled with the lack of partner support, in addition to the responsibility of securing good childcare during the daytime.

I had a lot of stress because I couldn’t find good childcare. At the time, my youngest was in kindergarten, and she would just go up to the teacher and say she had a tummy ache, and then the teacher would have to call me and say you have to come and pick her up. And I’m at the middle of day of work, 45 minutes away. So I had to cancel all my patients, get in the car, drive all the way home, and pick her up. We had a problem getting childcare on a regular basis. So that was very stressful. And I felt like I wasn’t getting a lot of support from my husband at the time. (WI-32)

The survey findings concurred with this subtheme, as 29.9% of female dentists and 11.9% of male dentists experienced stress related to caring for children. Additionally, nearly 16% of female dentists and 9% of male participating dentists reported stress related to taking care of others outside of work (Table 2). The analysis indicated a statistically significant difference between female and male participants for several non-work-related stressors, including taking care of children (p = 0.0001), taking care of others outside work (p = 0.046), time pressure (p = 0.0029), and emotional or mental health issues (p = 0,0029), where more female dentists have reported experiencing those stressors in comparison to male dentists (Table 2).

Supports and Interventions Needed

In addition to describing the challenges, participating dentists and stakeholders identified a number of organizational and systemic mental health and well-being support resources and interventions. Table 3 highlights some of the promising practices across Canadian provinces. Many recommendations were centered on prevention, awareness, and early integration of mental health into the dental curriculum, while others suggested some interventions to support dentists who are already struggling with mental health issues. Of note, participating dentists and stakeholders have indicated that there were no formal evaluation processes currently taking place for these practices and interventions. In the subthemes below, the participants’ support needs and recommendations are explicated.

Table 3.

Promising Practices That Various Canadian Organizations Have Developed and Implemented to Support Dentists’ Mental Health and Well-being.

Organization	Program/Initiative	Description
CDSPI	Member’s Assistance Program	The program is available to dentists who are members of some Provincial and Territorial Authorities, including British Columbia, Ontario, New Foundland and Labrador, and Nova Scotia.
British Columbia Dental Association (BCDA)	Dentist Wellness Program (DWP)	An early intervention program funded by BCDA. The program was launched in May 2019 to assist practicing dentists in dealing with mental health issues (including addiction) in response to dentists’ need for a dentist who can relate to their struggles and understand what happens with challenging patients and practice management. As a part of the program, counseling services are available to dentists, dental staff, and their families.
Alberta Dental Association and College	Wellness Program	A confidential program that involves 11 dentists who act as first-line responders and refer dentists and their family members to registered psychologists (for a quote, see interview 16).
Ontario Dental Association (ODA)	Wellness Program and Newsletter	The program provides ODA members with access to a phone line staffed by different dentists at the other end, in addition to providing dentists with access to online counseling. The ODA also addresses issues of mental health in their newsletter and has organized an online workshop to discuss mental health, stressors, and coping strategies for dentists.
Newfoundland and Labrador Dental Association (NLDA)	Wellness Committee and Newsletter	The committee has set up a wellness booth in the Association’s annual conference. The association has also designated a page in their newsletters to destigmatize help-seeking for mental health issues (see interview 6 for a quote).
Royal College of Dental Surgeons of Ontario (RCDSO)	Wellness Initiative	The initiative aims to help dentists access necessary treatment through designated facilities, particularly those with addiction issues (Stakeholder-3 ON).
University of Saskatchewan Faculty of Dentistry	Students’ Wellness Committee and Faculty-Specific Interventions	Students have a Mental Health and Wellness Committee (see interview 11). The Faculty of Dentistry is liaising with the University’s Wellness Centre to provide a session during orientation week to discuss mental health, self-care, and well-being of students.
University of Toronto Faculty of Dentistry	Mental Health Lunch and Learns	The Lunch and Learn Sessions aim to discuss the mental health and well-being of dental students throughout their careers in dental school, in addition to providing support to students through the Students’ Services Offices.

Early awareness and destigmatization of mental health issues

Many dentists and stakeholders suggested that identifying the mental health issues experienced by dentists is crucial to prevent them from progressing into more severe forms. Another form of awareness that has been brought to light is the awareness of the dentists’ own limitations. The issue of destigmatizing mental health issues and creating a culture that is supportive of dentists’ overall health was also emphasized.

I would destigmatize it [MH issues]. I think it’s so important. I would also make it a cultural responsibility . . . that your health is a valued and important part about your work. (WI-15)

It has also been suggested that once the problem is identified, it is important to seek help whether that is in the form of a conversation with a mental health professional or the individual in charge in the work environment.

Mental health, resilience, and practice management content in the dental curriculum

Participating dentists suggested that dental schools should introduce the concepts of mental health, coping, and stress management skills into the curriculum. One dentist described their dental education experience in the following quote, where resources about mental health were lacking:

In my dental school, there were no courses about mental health. I was aware that there’s a problem with dentistry, because some of the teachers would tell us, warn us, that it’s going to be stressful out there. They would warn us for the future. But there was no suggestions about what to do about that stress. It was just. . . . They just told us that it’s a matter of fact, that there’s stress. (WI-32)

Interviewees also called for increasing the dental schools’ involvement in preparing the students for the reality of practice management and the associated stressors. Participating dentists outlined the importance of integrating business management courses within the dental curriculum, as this integration has been thought to “set you up for more success for the future and make you more capable of handling the ins and outs of the rigor of dentistry, because it’s as much a business as it is a clinical profession” (WI-15).

Expanding dentistry-specific interventions

Dentists and stakeholders emphasized the significance of designing mental health interventions and resources that tackle the unique work circumstances of dentists:

The problems that physicians face and the problems that dentists face are quite different. And I would really like to see us at least go back to somebody who has a little bit more understanding about particular problems that dentists encounter, because many of them are work-related. (WI-8)

Many dentists felt that being involved in online groups to discuss various topics was helpful, where they had the opportunity to engage in conversations around resources, issues, and stressors. For many participating dentists, those groups helped them combat feelings of loneliness and isolation and were reported to be therapeutic in many ways. Furthermore, participating dentists highlighted that involvement in organized dentistry had a positive impact on their mental health, as it provided dentists with a sense of community and purpose.

We all have a WhatsApp group. We check in daily so if one of us has a bad day, we vent. We feel better after venting. If one of us has a good day. We celebrate, for example, . . . the weekend before last weekend. It was my birthday on the Saturday, I was able to get my second dose and wife is able to get a second dose and our kids got their first dose. So I called it [Dentist X] family vaccine weekend. And everyone was so happy. They’re cheering me on and it was awesome. It was just people who are good, getting together and sending positivity to each other. (WI-16)

Women’s involvement in organized dentistry was also identified as a promising practice by participating stakeholders and dentists. In addition to its role in creating a sense of community among the women in the profession, female dentists highlighted the supportive and empowering role of these organizations, particularly for issues and challenges related to practice management and ownership.

Mentorship initiatives

To address the isolation associated with practicing dentistry, in addition to bridging the gap between the job market and dental schools, participating dentists suggested that dental associations should create formal mentorship programs for newly graduated dentists. One practice owner highlighted the role of these programs in supporting dentists’ overall mental health and well-being by giving them a sense of reassurance and community:

[Being] able to have somebody to back you to be able to have somebody to call upon, being able to have somebody to ask questions, even some as simple as what would you do for this or that, and some of the more complex stuff. (WI-23)

Discussion

This mixed-methods study explored the challenges experienced by dentists in Canada and the impact of these challenges on their mental health and overall well-being. The findings offer an in-depth understanding of the professional, personal, family, and structural factors that shape dentists’ mental health and well-being. Across each of these categories, gender roles’ influences, particularly with regard to the dentists’ professional roles and responsibilities, were a key factor. This comprehensive understanding was facilitated by using qualitative interview data and triangulating them with quantitative survey findings. Additionally, by highlighting the challenges, the study moved beyond the deficit approach to bring forward the promising practices and recommendations that can promote and maintain dentists’ mental health and well-being.

The challenges experienced by the participating dentists in this study were focused on the reality of the profession, the participants’ personal attributes and identities, and the interactions of these identities with social and structural elements in the profession. For instance, the dentists’ gender identity, particularly identifying as a woman, was found to increase stress and contribute to their anxiety, depression, and burnout. These findings were consistent with the literature, as 1 study reported that male dentists were more likely to own dental practices in comparison with female dentists in Ontario (McKay et al. 2016). Another study showed that female dentists were reportedly 2 to 3 times more likely to work as associates than male dentists, who were more likely to run practices (Surdu et al. 2021). Both studies attributed this finding to the desire for flexibility and accommodations of female dentists, with one indicating that familial responsibilities were found to be a significant predictor of practice ownership for female dentists but not for men (McKay et al. 2016). Despite the benefits that the associateship model may offer for female dentists, evidence suggests that associateship in the dental practice was found to be correlated with burnout and emotional exhaustion, as well as a contributing factor to the gender-related compensation gap between men and women (Vujicic, Yarbrough and Munson 2017; Gómez-Polo et al. 2022).

The challenges experienced by participating dental practitioners in the domain of patient care seem multifaceted and complex, reflecting stressors in both work responsibilities and environment. There is evidence supporting some findings, as the dentists working in rural areas in the study carried out by Gómez-Polo et al. (2022) were more prone to burnout. Further, the issue of ethical dilemmas and moral distress augments the dentistry literature, despite some schools’ efforts in addressing this issue in the dental curriculum (Maragha et al. 2022, 2023). Given the paucity of evidence about the contributing factors to dentists’ overall mental health and well-being in different work settings, large-scale studies are needed to explore these factors and develop support mechanisms and policies accordingly.

Our findings revealed that more women participating dentists in this study reported mental health issues compared to male participants in the survey data, which aligns with the current literature and suggests that women are more likely to experience burnout, emotional exhaustion, anxiety, and lower resilience levels (Kulkarni et al. 2016; Gómez-Polo et al. 2022; Hopcraft et al. 2023). In contrast, less evidence is available about the mental health challenges experienced by other gender identities in the dental practice, including transgendered individuals, which remain to be explored by future studies.

Many studies have focused on the stressors and mental health issues experienced by dental students as opposed to practicing dentists (Gallagher et al. 2021). However, practicing dentistry independently is associated with its unique challenges that shape the dentists’ mental health differently. Further, the practice of dentistry is different in various parts of the world, as some dentists graduate from their dental programs in their early 20s and without a previous degree, which is not the case for most recent graduates in Canada and the United States (Sonkar et al. 2020). As this reality cannot be captured by focusing solely on the North American dentistry context, future studies can address this gap and examine the mental health experiences among dentists in other regions in the world.

Participating dentists and stakeholders revealed several promising practices with regard to their mental health and well-being, including organized dentistry initiatives, wellness programs, and initiatives to destigmatize mental health issues and expand early awareness initiatives and interventions, particularly those that are tailored to the needs of dentists. However, it should be noted that all practices identified in the study targeted the individual dentists’ mental health (Plessas et al. 2022), as opposed to being organizational strategies that could drive potential systemic change in the current situation of dentists’ mental health. Therefore, organizations can build on these practices, as well as expand and translate them into national actions and work plans that contribute to making the profession more supportive of the dentists’ well-being. Additionally, many of these practices are described as more generic in nature, but attention to the unique experiences of women and individuals with other gender identities is warranted considering our findings.

Furthermore, the interview participants, particularly stakeholders, indicated that there was no formal evaluation process for any of these programs. This, in turn, may raise some concerns about the sustainability, effectiveness, and relevance of these programs. The lack of evidence supporting the impact of these initiatives may also have policy implications, as regulatory bodies and other relevant stakeholders may hesitate in adopting and funding these practices or expanding them, which may jeopardize the dentists’ mental health and limit the available resources to them. Therefore, researchers can address this gap and collaborate with organizations to evaluate the effectiveness of these interventions and practices. Additionally, following the integration of the suggestions provided by interviewee dentists for the current programs, future studies can explore the possibility of extending them into other health professions and identify opportunities for interprofessional initiatives to support the health and well-being of the health care workforce.

There are some limitations of our study for consideration. First, data collection process took place during the COVID-19 pandemic, which may have impacted the dentists’ mental health and overall well-being. However, this contextual element was addressed to some extent by including survey and interview components that are specific to COVID-19 and asking participants to reflect on their experiences prior to the pandemic. Second, this study, although encompassing a wide range of dentists from various age groups, practice settings, and sexes, only represented a limited purposeful sample of the Canadian dentists. This raises issues about the transferability of the study findings to other settings. However, future researchers in other settings can use the findings to generate hypotheses and research questions to explore in their settings. Lastly, our participants were dentists in Canada, where the dominant practice model is self-employment and business ownership of private dental offices (Shaw and Farmer 2015). Consequently, the challenges arising from this practice model may not apply in other parts of the world, where dental care is run by governments with dentists as government employees. Despite this limitation, we believe that our study can inform future studies to explore the mental health experiences of dentists in their unique practice contexts and inform the development of strategies and programs to promote and maintain their mental health and well-being.

Conclusion

This study explored the mental health experiences of Canadian dentists using a mixed-methods research study to capture the experiences and responses from stakeholders and practicing dentists in various settings. Sex/gender emerged as a contributing factor that shaped the challenges experienced by dentists both personally and professionally, which entails further studies to design and implement gender-specific interventions to support dentists’ mental health.

Author Contributions

T. Maragha, contributed to data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; J. Atanackovic, contributed to design, data acquisition and analysis, critically revised the manuscript; T. Adams, M. Brondani, contributed to design, critically revised the manuscript; I. Bourgeault, contributed to conception, design, data analysis and interpretation, critically revised the manuscript. All authors have their final approval and agree to be accountable for all aspects of work.