41 JANUARY-FEBRUARY 1999
JOURNAL OF DENTISTRY FOR CHILDREN
A study of psychological stress
created in dentists by children during
pediatric dental treatment
R .esearch on stress in the workplace was pioneered
by Kahn et al} Such work initially focused on how
stresses generated by workplace stressors relate to
particular symptoms. Recent studies have examined
how such effects are enhanced or alleviated by traits
of the individual or by characteristics of the work
organization.2 In Japan, an investigation by Iida et al
demonstrated that stress in the workplace powerfully
affects life away from work.3 At the same time, cer-
tain stress related syndromes are coming into focus. In
the medical profession, rapid advances in technology
have been likened to a "burn-out syndrome" increas-
ingly prevalent among doctors, nurses, and other
health care specialists. In modern society, stress is so
ubiquitous and diverse that specific countermeasures
are difficult to design. Thus, comprehensive inter-
disciplinary research, bringing to bear in medicine
expertise from the fields of psychology and sociology,
is required. Hence, it was seen as beneficial to exam-
ine work-related psychological stress as it appears
in the field of dentistry.
Research on stress in dentistry was first reported by
Howard et al in 1976.4 He reported the general finding
that dentists experience considerable stress in the
All of the authors are with the Department of Pediatric Dentistry,
School of Dentistry, Hiroshima University.
Myoyo Kan, DDS
Takayoshi Ishikawa, DDS, PhD
Nobuo Nagasaka, DDS, PhD
course of examination and treatment. The need to
limit treatment times, to be perfect in diagnosis and
technique, to reduce the pain and discomfort of the
patient, to deal with canceled appointments and
patients who arrive late, and to handle patients dis-
playing various levels of cooperativeness—all have
been shown to be significant sources of stress accom-
panying routine dental practice.
A dentist's office is an inherently stressful workplace.
Human beings arrive in pain, vulnerable to further
injury, both mental and physical. Errors are not allowed.
Like physicians, dentists work under an intense and
constant pressure to be perfect, found only in jobs
where the worker is entrusted with human lives.5 Given
that the practice of dentistry is inherently stressful,
learning to live with stress is clearly an imperative of
the profession.
In the United States and Europe, the stress created
in patients by dental treatment and the stress experi-
enced by dental practitioners have been studied for
decades.615 In pediatric dentistry, however, studies
have examined the stress on the patients, but very
little work has been done on the stress experienced
by the dentist.16"21 In pediatric dentistry, dental treat-
ment typically takes place in the context of a three-
way relationship among the dentist, the patient, and
the patient's guardian. In most cases, the child is

accompanied by a guardian, and the treatment cannot
take place without that guardian's cooperation. Thus,
it can be assumed that the guardian's presence in the
treatment setting will generate some sort of psycho-
logical stress. The authors have previously studied
psychological stress created in dentists by guardians.2225
In the present study, the orientation was shifted to the
stress created by the child in the dentist.
In the dental treatment of children, children often
express such emotions as anxiety and fear, accompa-
nied by recognizable bodily changes. The present
study will report on the psychological influence of
such emotional behaviors on dentists performing
dental treatment.
MATERIALS
Twenty-five dentists participated in developing an
instrument for measuring the psychological stress
(hereinafter "stress") created in dentists by children
during pediatric dental treatment. Of these, eleven
were male, fourteen were female, and all were prac-
ticing in the pediatric dental clinic associated with the
Department of Dentistry, Hiroshima University. The
same subjects were utilized in testing the validity and
reliability of the instrument.
METHODS
Creating the Child-to-Dentist
Psychological Stress Response Scale
• Creating a self-report questionnaire
Emotional behavior in children can be broadly divided
into external behaviors that can be readily observed
(bodily movement, facial expressions, and speech) and
less easily observed internal changes (perspiration,
changes in breathing, and pulse rates). The present
study used the external (observable) behavior of chil-
dren to study the stress produced in dentists by the
behavioral expression of emotions during dental treat-
ment and examination. The external behaviors of the
children during treatment have been studied by
Kurosu et al and many other researchers.26 The present
study used the items of observation (external behaviors
of children) identified by Tsuchiya et al.17 The external
behaviors observed were those deemed to be bodily
expressions of anxiety and fear in the children related
to dental treatment, and specifically those behaviors
that tend to interfere with treatment. These behaviors
were identified and observed through videotape, audio
42 JANUARY-FEBRUARY 1999
JOURNAL OF DENTISTRY FOR CHILDREN
Table 1 CD Observable stress response.
Body (or limbs) Mouth and Tongue
1. Body stiffening 1. Holding breath
2. Shaking
3. Raising hands or legs
2. Wanting to gargle
3. Moving mouth or tongue
4. Raising torso 4. Immediately closing mouth
5. Thrashing legs
6. Seizing practitioner's hand
5. Closing mouth, refusing to open
6. Covering mouth with hands
7. Brushing away the
practitioner's hand or
instrument
Eyes and Facial Expression Voice
1. Staring at instruments 1. Sudden exclamation of surprise
2. Closing eyes 2. Asking "What are you going to do?"
3. Excessive eye movements 3. Bursting out crying
4. Face on the verge of tears
5. Hiding face
4. Sobbing plaintively
5. Repeated shouts of pain
6. Shouting "No, no."
7. Loud, continuous crying
recordings, and an observation checklist. Tsuchiya's
external, observed behaviors included seven of the
body (and limbs), six of the mouth and tongue, five of
the face and eyes, and seven of the voice. The present
study adopted Tsuchiya's twenty-five behaviors in
preparing a preliminary questionnaire designed to
measure the stress produced in dentists by children
during pediatric treatment (Table 1).
• Selecting the stress response items, compiling the scale
After fully explaining the purpose of the present study
and obtaining fully voluntary agreements, a preliminary
questionnaire was administered based on Tsuchiya's
twenty-five external behaviors. Each behavior was
rated by each subject, who assigned a 'degree of stress'
the dentist received from the child during treatment.
The system was as follows: If the behavior was experi-
enced as producing "no stress at all," it was scored 0.
If it was associated with "mild stress," the score was 1,
"significant stress" was scored 2, and "high stress" was
scored 3.
The authors acknowledge that the child's age, gen-
der, the nature of the procedure, and other situational
factors are relevant to the perception of stress. The sub-
jects were asked to respond generally, however, based
on their "overall clinical experience to date." Thus,
twenty-five dentists rated a total of twenty-five child
patient behaviors in terms of subjective degree of
stress. The scores obtained from the preliminary ques-
tionnaire were subjected to factor analysis to select the
items with especially high concrete homogeneity.28
The primary factor method was used, a method com-
monly used in cases where the most appropriate method
of factor extraction is not clear.2930 Extracting factors
with an eigenvalue of 1.0 or more (Guttman's weakest
lower bounds), we performed a Varimax factor rotation

to obtain factor loads that can be more easily explained.31
The factors were named in accordance with the abso-
lute value of the factor load.
• Creating the Child-to-Dentist
Psychological Stress Response Scale
Initially, the items selected were those with a high
factor load in the first factor. The factor loads for all
items were 0.40 or greater. Because some items par-
ticipated in two or more factors, however, items with
loads of 0.50 or less were dropped. To avoid factor
loads involving two or more factors, only items with
absolute factor load values above a certain standard
were selected for the final questionnaire.
The answers to the items on the final scale utilized the
four-level method commonly used for self-report sur-
veys. The criteria were the same as those used for the
preliminary questionnaire.
The score for the scale as a whole was the sum of the
scores for each item. Thus, the higher the score, the
greater the stress created by the child during treatment
as reported by the dentist.
Studies of the reliability and validity of the Child-
to-Dentist Psychological Stress Response Scale
\3Reliability
To study the reliability of the instrument created for
this study, the authors sought the probability of passage
and the reciprocal correlation for each item using the
tests most commonly used to determine general reli-
ability. Internal consistency was evaluated based on
these tests. The test/re-test method was used to find the
correlation between scores when the same test was
administered to the same subjects after a given interval
of time. Cronbach's coefficient was used to examine the
consistency with which the item on the scale actually
measured psychological stress response.32 This is the
test of internal consistency most commonly utilized for
estimating the coefficient of reliability for a total score
obtained from a number of variables.
To investigate stability over time, the same instru-
ment was administered to the same subjects after an
interval of one week. The scores on the two tests were
compared using Spearman's rank correlation coeffi-
cient.33
Validity is the extent to which a given instrument actu-
ally measures what it purports to measure. Tests of
validity are especially important in the measurement of
intangible psychological phenomena. The present
43 KAN, ISHIKAWA, NAGASAKA
PSYCHOLOGICAL STRESS IN DENTISTS
scale was examined for both concurrent validity, a
criterion-related validity, and factorial validity, a form
of structural validity.
Concurrent validity attempts to establish the validity
of the scale in question by comparing it to a scale that
has already been shown to measure a related phenom-
enon. Because no standard scale exists for measuring
stress in dentists created by children during dental
treatment, the authors turned to the more generalized
Psychological Stress Response Scale (hereinafter "PSRS").34
This is a scale designed to evaluate through self-
report qualitative and quantitative psychological
stress response to generally recognized stressful life
events. The scores obtained by the subjects on this
general PSRS were compared to their scores oh the
Child-to-Dentist Psychological Stress Response Scale
using the Spearman coefficient.33
In addition, the average total scores from the PSRS
were used to divide the subjects into a high-stress group
and a low-stress group. These groups were compared
to similar groups formed based on scores from the
Child-to-Dentist Psychological Stress Response Scale
using the Mann-Whitney U-test.35 Finally, the high-
stress and low-stress groupings were used to study
the scores for each item on the Child-to-Dentist Psycho-
logical Stress Response Scale.
Factor analysis was used to study constructive valid-
ity.28 Searching factor analysis is often used to examine
the validity of scales in the fields of psychiatry and
psychology. Factor analysis, based on the principle of
parsimony, is an attempt to explain, by the common
constituents of fractions, the relationship between
multiple measured values. Ordinarily, in creating a test
that measures simple traits, the reliability of the test
can be improved by using large numbers of questions.36
The factor validity of this scale was examined by find-
ing the factor loading for twenty-five questions. When
questions influenced by two or more factors were
eliminated, twenty-one items were retained for the
final self-report instrument. Confirmatory factor analy-
sis was performed for these twenty-one items.
RESULTS
Creation of the Child-to-Dentist Psychological
Stress Response Scale
D Selection of stress response items, building the scale.
Scores on all items were subjected to factor analysis
and, by primary constituent analysis, three factors
were extracted. Six factors with eigenvalues of 1.0
 44 JANUARY-FEBRUARY 1999
JOURNAL OF DENTISTRY FOR CHILDREN

were found. Based on an eigenvalue graph, however,

and using the curve method, which determines the Table 2 CD Factor structure of 25-item preliminary questionnaire.
number of factors by the number of eigenvalues that Items First factor Second factor Third factor
appear before a sudden change in the graph, three Excessive eye movements 1.015 -0.015 -0.258
Immediately closing mouth 0.928 -0.271 0.065
factors were identified. Staring at instruments 0.882 0.115 -0.092
Closing mouth, refusing
The factor structure is shown in Table 2. The first to open 0.839 -0.352 0.085
Moving mouth or tongue 0.744 -0.205 0.195
factor was termed "stress on dentists due to moderate Covering mouth with hands 0.692 -0.395 0.476
resistance behavior." This factor derived from ques- Sudden exclamation of
surprise 0.545 0.215 0.036
tions about closing the mouth, covering the mouth Asking "What are you going
to do?* 0.492 0.110 0.178
with the hand, hiding the face, and the like. The second Hiding face 0.460 0.273 0.250
factor was termed "stress on dentists due to slight Bursting out crying -0.379 0.959 0.074
Face on the verge of tears -0.018 0.849 -0.323
resistance behavior." This factor derived from questions Wanting to gargle -0.433 0.801 0.318
regarding frantic eye movements, body stiffening, Body stiffening 0.179 0.769 -0.139
Holding breath 0.048 0.742 -0.043
holding the breath, fighting tears, and the like. The Sobbing plaintively -0.350 0.679 0.452
Shaking 0.326 0.475 -0.000
third factor was termed "stress on dentists from deter- Closing eyes 0.284 0.412 -0.079
mined resistance behavior." This factor derived from Seizing practitioner's hand
Brushing away the
0.003 -0.098 0.978

questions regarding thrashing of legs, pushing away practitioner's hand

or instrument -0.003 -0.000 0.891
the dentist's hand or instrument, screaming OW! or Thrashing legs -0.081 0.178 0.872
other expressions of pain, loud crying, and the like. Raising hands or legs
Loud, continuous crying
0.074
-0.125
0.156
0.030
0.751
0.715
Shouting, "No, no." 0.481 -0.451 0.666
\Z\Selection items for the Child-to-Dentist Psychological Repeated shouts of pain 0.204 0.020 0.611
Raising hands or legs 0.168 0.281 0.525
Stress Response Scale Eigenvalue 10.888 2.914 2.209
Accumulated factor
Because several items were duplicated within factors, contribution (%) 43.6 11.7 8.8
all items with absolute factor loading values of 0.40 Absolute values of 0.40 or higher shown in bold print

Table 3 CD Variance-covariance matrix.

No. 1 No. 2 No. 3 No. 4 No. 5 No. 6 No.7 No. 8 No. 9 No. 10 No. 11 No. 12 No. 13 No. 14 No. 15 No. 16 No. 17 No. 18 No. 19 No. 20 No. 21
Nal 0.410
2 0.290 0.843
3 0.260 0.648 0.777
4 0.222 0.545 0.647 0.640
5 0.205 0.603 0.672 0.632 0.873
6 0.240 0.518 0.598 0.562 0.787 0.777
7 0.413 0.353 0.338 0.298 0.332 0.370 0.790
8 0.185 0.390 0.327 0.297 0.280 0.257 0.322 0.627
9 0.123 0.385 0.315 0.295 0.312 0.227 0.145 0.182 0.593
10 0.057 0.285 0.248 0.220 0.237 0.210 0.070 0.073 0.327 0.477
11 0.078 0.113 0.237 0.177 0.227 0.222 0.185 0.045 0.280 0.355 0.590
12 0.100 0.358 0.308 0.300 0.383 0.358 0.133 0.058 0.317 0.317 0.325 0.500
13 0.287 0.363 0.362 0.260 0.310 0.305 0.310 0.087 0.322 0.397 0.382 0.325 0.673
14 0.252 0.282 0.227 0.122 0.188 0.190 0.230 0.027 0.282 0.298 0.303 0.267 0.470 0.510
15 0.218 0.190 0.110 0.105 -0.037 -0.027 0.297 0.327 0.107 0.082 0.070 0.058 0.195 0.060 0.527
16 0.178 0.472 0.337 0.310 0.360 0.288 0.277 0.312 0.430 0.380 0.165 0.283 0.415 0.278 0.295 0.740
17 0.160 0.123 0.093 0.138 0.038 0.073 0.163 0.310 -0.085 0.015 -0.047 -0.025 0.078 0.000 0.218 0.053 0.493
18 0.220 0.388 0.337 0.352 0.360 0.330 0.277 0.437 0.138 0.130 0.082 0.158 0.290 0.153 0.253 0.195 0.512 0.823
19 0.167 0.458 0.458 0.458 0.500 0.417 0.167 0.292 0.375 0.333 0.333 0.250 0.375 0.208 0.167 0.333 0.125 0.417 0.750
20 0.100 0.358 0.392 0.383 0.508 0.442 0.092 0.017 0.400 0.275 0.325 0.500 0.367 0.308 -0.025 0.242 -0.025 0.325 0.417 0.833
21 0.107 0.193 0.340 0.370 0.387 0.368 0.178 0.123 0.110 0.135 0.205 0.317 0.247 0.098 0.090 0.105 0.190 0.438 0.333 0.483 0.710

Table 4 CD Average scores and standard deviation on the Child-to-

Dentist Psychological Stress Response of the high and low stress groups
identified by the PSRS.
Average score (S.D.)
High stress level groups (N= 9) 36.77 (8.37)
Low stress level groups (N=16) 27.06 (11.33) II-
(): standard deviation
* : significantly different (p<0.05)
 45 KAN, ISHIKAWA, NAGASAKA
PSYCHOLOGICAL STRESS IN DENTISTS

Table 5 CD Average scores and standard deviation on the Child-to-Dentist Psychological Stress Response Scale of the high and low stress groups
identified by the PSRS.
No 1 No. 2 No. 3 No 4 No. 5 No. 6 No.7 No. 8 No. 9 No. 10 No. 11 No. 12 No. 13 No. 14 No. 15 No. 16No. 17 No. 18 No. 19 No. 20 No. 21
High stress 1? 2.2 2.3 2.2 ?,5 2.6 1.6 1.3 2.0 1.6 2.2 2.2 0.8 0.7 0.8 17 1.1 15 2.1 2.0 17
level groups (0.6) (0.6) (0.5) (0.4) (0.5) (0.5) (1.0) (0.7) (0.7) (0.7) (0.8) (0.6) (1.0) (0.9) (0.6) (0.6) (0.7) (1.0) (0.9) (1.0) (1.0)
Low stress 1.0 1.1 1.6 1.6 1.7 1.8 0.8 1.2 1.3 1.1 1.5 1.5 0.3 0.3 0.8 1.0 1.0 1.2 1.9 1.6 1.6
level groups (0.6) (0.8) (0.9) (0.8) (1.0) (0.9) (0.8) (0.8) (0.7) (0.6) (0.8) (0.6) (0.4) (0.4) (0.8) (0.7) (0.6) (0.8) (0.8) (0.8) (0.7)
Significantly
different ** * ** * * * *
): standard deviation
* : significantly different (p<0.05)
**: significantly different (p<0.01)

Table 6 CD Factor structure of the 21-item final questionnaire. The rank correlation of scores on the Child-to-Dentist
Items First factor Second factor Third factor
Psychological Stress Response Scale and the PSRS
Excessive eye movements 0.873 0.145 -0.142
Immediately closing mouth 0.829 -0.000 0.046 was found to be rs = 0.46, confirming a correlation sig-
Staring at instruments 0.826 0.268 -0.015 nificant to 5 percent. Based on the average score of
Closing mouth, refusing
to open
Moving mouth or tongue
0.733
0.696
-0.097
0.018
0.065
0.161
38.8 on the PSRS, the subjects were divided into a
Sudden exclamation of high-stress group and a low-stress group. When these
surprise 0.635 0.370 0.000
Covering mouth with hands 0.562 -0.167 0.463 groups were compared based on their points from the
Face on the verge of tears 0.321 0.841 -0.378 Child-to-Dentist Psychological Stress Response Scale,
Bursting out crying -0.265 0.766 0.073
Wanting to gargle -0.080 0.750 0.213 the difference between the two groups was significant
Body stiffening 0.309 0.659 -0.000
Molding breath 0.227 0.624 0.059
to 5 percent (Table 4).
Sobbing plaintively -0.092 -0.606 0.413 Table 5 shows the standard deviation of item scores
Seizing practitioner's hand 0.000 -0.030 0.945
Brushing away the practitioner's for both groups on the Child-to-Dentist Psychological
hand or instrument
Thrashing legs
0.000
0.000
0.021
0.176
0.895
0.859
Stress Response Scale. For two items, the difference
Raising hands or legs 0.116 0.178 0.756 was significant at the 1 percent level. For eight items,
Loud, continuous crying -0.055 0.046 0.686
Shouting "No, no." 0.353 -0.261 0.643 the differences were significant at the 5 percent level.
Raising hands or legs 0.247 0.330 0.519
Repeated shouts of pain 0.308 0.184 0.503 Thus, dentists who scored high in stress from ordinary
Eigenvalue 9.235 2.871 2.100 life events also scored high on the Child-to-Dentist Psy-
Accumulated factor
contribution (%) 44.0 13.7 10.0 chological Stress Scale. The converse was true as well.
Absolute values of 0.50 or higher shown in bold print The factor loading shown in Table 6 shows that none
of the items is duplicated within a single factor. All
twenty-one items demonstrated factor load values of
or less were eliminated. Ultimately, twenty-one ques- 0.50 or greater. Thus, each item demonstrated excellent
tions were retained for the final scale, seven for factor factor validity, and all items were deemed to measure
1, six for factor 2, and eight for factor 3. the psychological stress experienced by dentists due to
the behavior of children during dental treatment.
Reliability and validity of the Child-to-Dentist DISCUSSION
Psychological Stress Response Scale
It is said that we live in an age of stress. With the burn-
{^Reliability out syndrome among physicians, nurses, and other
The internal consistency of the stress response mea- medical professionals attracting increasing attention, it
sured by each item was sought, using Cronbach's coef- is clearly necessary to investigate occupational stress
ficient to generate the covariance matrix shown in Table in dentistry as well. These studies should focus on elu-
3.32 The reliability coefficient thus obtained was a high cidating ways of avoiding stress, ways of coping with
a = 0.97. Stability over time was sought by evaluating stress, and any potential way to make the dentist's
the rank correlation of total score on the first and workplace less stressful. To this end, we believe it was
second tests. A correlation coefficient of rs = 0.91 was useful to create a psychological stress response scale
obtained, confirming a positive correlation significant with which to study an aspect of the stress to which
to 0.1 percent. dentists are subjected.

In the present study, factor analysis revealed three
factors related to the stress dentists receive from chil-
dren during treatment: stress from mild resistance
behavior, stress from moderate resistance behavior,
and stress from determined resistance behavior. Of
these, it was found that dentists report greatest stress
from the behaviors associated with moderate resis-
tance. Kurosu et al studied the effect of certain external
behaviors on treatment, seeking to identify which
behaviors were the most difficult to handle.37 The be-
haviors of children were classified into three levels by
the extent to which each interfered with treatment.
The first level (Degree of Difficulty 1) included behav-
iors that, while recognizable, did not interfere with
treatment. The second level (Degree of Difficulty 2)
included behaviors that "somewhat interfered" with
treatment. The third level (Degree of Difficulty 3)
included behaviors that "obviously interfered" with
treatment. Based on "degree of difficulty" alone, one
would expect that in our study dentists would experi-
ence the most stress from "determined resistance,"
followed by "moderate" and "mild" resistance. Our
scale revealed, however, that moderate resistance gen-
erated the most stress, followed by determined and
mild resistance. One explanation for this result may be
the fact that the dentists recognize determined resistance
immediately and are able to prepare themselves psy-
chologically to meet the challenge. Thus, the most
overt behaviors are experienced as less stressful.
The creation of an effective scale requires attention
to both the content and statistical aspects. Is the distri-
bution of items balanced with respect to the overall
purpose of the scale? Is each item truly necessary?
Such questions must be examined in detail.36 In study-
ing the reliability of instruments used to measure psy-
chological phenomena, the most common approach is
via internal consistency which evaluates the accuracy
of the measurement in terms of the consistency of the
constituent elements.38 This study of internal consis-
tency can verify the hemogeneity of items within the
instrument. If the test is administered only once, it is
impossible to determine the stability of the result over
time, that is, the extent to which the first result depends
on spurious time-related factors. The test/re-test method
uses the results of the same test given to the same sub-
jects after a given interval of time to determine the
stability of the values measured.
One way to create a highly reliable scale is to include
a large number of items. The need to minimize testing
times and subject fatigue, however, precludes indefi-
nite increases in the number of items. The present scale
46 JANUARY-FEBRUARY 1999
JOURNAL OF DENTISTRY FOR CHILDREN
was evaluated for both internal consistency and sta-
bility over time. The internal consistency was a = 0.97.
For most purposes, a reliability coefficient of a = 0.80
or higher is acceptable. Our scale far exceeded that
requirement, thus confirming that all the items
measure a similar phenomenon (with respect to the
measurement of psychological stress created in dentists
by children during dental treatment). In examining
stability over time, a high ranked correlation of rs = 0.91
was found, confirming the stability of the measure-
ment with repetition. Further, the scale created here
consists of only twenty-one questions and requires only
about five minutes to administer, eliminating the issues
of testing time and subject fatigue.
The concept of validity is used to examine the cru-
cial question of whether a given instrument measures
what it purports to measure. A given scale is deemed
appropriate, if the target of the instrument's measure-
ment and if the standard for external behavior are
clear.36 Validity is evaluated by comparing properties of
the behavior, external variables or a standard measure-
ment to scores on the scale being created. Even a con-
crete, well-constructed scale may not measure, however,
the constituent concepts originally hypothesized. Fac-
tor analysis is a method that attempts to demonstrate
the relatedness of a number of measured values in terms
of the common constituents of fractions.
In the process of selecting items for a given scale, it
is important to examine the mutual correlation among
items and first factor loading.36 To satisfy this require-
ment, we studied two types of validity. We used the
PSRS, an accepted instrument for measuring the stresses
of everyday life, as the standard for evaluating standard
validity. The high correlation we found between this
scale and our scale suggests that our scale does indeed,
measure psychological stress. The structural validity of
our scale was confirmed by factor analysis, further
establishing its validity as an instrument that measures
psychological stress. Thus, we believe the Child-to-
Dentist Psychological Stress Response Scale has satis-
fied substantial criteria for both reliability and validity
and should be accepted as an effective instrument for
measuring the psychological stress created in dentists
by children during dental treatment.
Statistics is an indispensable aspect of nearly all natu-
ral science research, and is becoming an increasingly
important interpretive method in dentistry. When
measuring an intangible phenomenon like psychologi-
cal stress, quantification relies on the subjective evalua-
tion of individual subjects. In the transformation of
subjective experience into objective points, therefore,

researchers have no way of establishing uniform in-
tervals between the points. The variables in this study
were ranked variables, therefore, and the data were
processed statistically, using Spearman's ranked corre-
lation coefficient and the Mann-Whitney U-test.33
We believe the scale we created can be used in similar
environments (pediatric dentistry, university clinic), but
is not applicable to dentistry in general. The Cronbach
a value for internal consistency is high in scales com-
posed of items highly correlated in the same dimen-
sion. The breadth of measurement of such scales,
however, is narrow.39 The a value of the present scale
is extremely high. All items specifically measure the
psychological stress dentists receive from children
during treatment, so the measurement is extremely
pure. The scores on the scale cover a narrow band of
measured values.
The scale measures psychological stress arising from
external behaviors of children that are comparatively
common, but there may be some less common behav-
iors that were not selected. In creating a scale, both the
population and target of measurement are limited, so
the scale must be built to match the specific research
topic. This customizing is important for increasing the
predictive power of the instrument. These problems
arise in the creation of any scale, so it has been pointed
out that scales should be created as required by the
subjects and environments involved.40 Our scale is no
exception. The purpose of this study was to investigate
whether and to what extent children produce stress in
their dentists. It was never intended as an instrument
for general dentistry. As the topic changes, new scales
will need to be created.
We intend to continue examining psychological stress
in dentists, specifically, the relationship to general anxi-
ety and other traits in the dentists themselves, coping
behaviors, and related issues.
CONCLUSION
Little research is available on the psychological stress to
which medical practitioners are subjected. The present
study examined the forms of stress observed at the
pediatric dental clinic with which the authors are asso-
ciated. In pediatric dentistry, the dentist is subject to
stress from two main sources, the child and the guard-
ian. The present study was a departure from the au-
thors' own previous research in that it focused on the
stress created in the dentist by the child.
In the course of dental treatment, children express
fear and anxiety, which are readily recognized from
47 KAN, ISHIKAWA, NAGASAKA
PSYCHOLOGICAL STRESS IN DENTISTS
expressive external behaviors. Using factor analysis, a
twenty-one-item self-report survey was created to
measure the psychological stress response in dentists
derived from such behavior.
The effectiveness of this scale was examined for
reliability and validity, and the following results were
obtained:
DThe twenty-one items in the scale were selected in
connection with three primary factors: stress
from mild resistance behavior, stress from moder-
ate resistance behavior, and stress from determined
resistance behavior.
• The scale demonstrated high internal consistency
and, by test/re-test, high stability over time.
• Concurrent validity was confirmed by the high
positive correlation between scores on a standard-
ized scale for psychological stress in everyday life
(PSRS) and scores on the scale created for present
study. The correspondence was significant beyond
5 percent. Factor validity was demonstrated by
confirmatory factor analysis, which showed that
the factor loading for all items on the scale was 0.50
or higher, with no duplication between factors.
The above findings indicate that the scale created for
the present study is an effective instrument for mea-
suring the psychological stress created in dentists by
children during pediatric dental treatment.
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SHOULD MEDICAL JOURNALS TRY TO INFLUENCE POLITICAL DEBATES?

Editors should be sufficiently humble to appreciate that what we write or publish

may have limited influence on political debates. Usually, we have little idea of the
effect. Nonetheless, I believe that medical editors have an obligation to publish not
only articles that are well reasoned, informative, and carefully reviewed, but also
ones that are sufficiently timely to contribute to the development of public policy.
Expediting a review and advancing the date of publication of a study or opinion
piece is often justified. Firing an editor for doing so is an irrational decision and an
ominous precedent.

Jerome P. Kassirer: Should medical journals try to influence political debates?,

New Engl J Med, 340:466-467, February 11,1999