Burnout syndrome in peruvian dental students: a prevalence study

Aim: Burnout syndrome describes the state of long-term physical, emotional and mental exhaustion related to work. This syndrome can cause health problems related to stress, insomnia, cardiovascular and musculoskeletal diseases, including an increase in alcohol consumption and drug use. It is important to recognize the presence of the initial signs of this syndrome, therefore this study aimed to determine the prevalence of the burnout syndrome in peruvian dental students. Methods: The study was observational, cross-sectional, and descriptive. It was carried out from September to November 2018


Introduction
Burnout syndrome describes the state of long-term physical, emotional and mental exhaustion related to work 1,2 .This syndrome can cause health problems related to stress, insomnia, cardiovascular and musculoskeletal diseases, including an increase in alcohol consumption and drug use 1,3 .In the United States, it has been reported that 25.2% of pediatric dentists experienced emotional exhaustion or depersonalization and 9.1% occupational burnout 1 .
University students are a group vulnerable to this problem, because they must meet demanding requirements in short periods of time 4 .For this reason, in recent years, research on this syndrome has not only been limited to the workplace, but also includes students 5 .
According to reports, burnout syndrome is common in Medicine and Dentistry students.This is due to the competitiveness of these programs and to the fact that students endure years of academic demands and high expectations from teachers, even at risk of developing mental disorders [6][7][8][9][10] .
According to Ghali and Awood 11 , there are several stress factors for dental students, including demanding exams, clinical care of patients in different courses, aggressive criticism from teachers, little time to complete clinical requirements and even technical problems related to the dental chair.Likewise, the professional career is expensive, creating, together with the aforementioned factors, a stressful environment for learning, which causes a negative impact on the academic development and general well-being of the student 12,13 .
To assess burnout syndrome in professionals, Maslach constructed the Maslach Burnout Inventory (MBI) scale.For their part, Schaufeli et al. proposed an adapted a version for students called the Maslach Burnout Inventory-Student Survey (MBI-SS) 14,15 , where they assess three key dimensions: Academic Self-Efficacy (ASE), Emotional Exhaustion (EE) and Cynicism (C) 16 .(Figure 1) Braz J Oral Sci.2024;23:e241300 Through this instrument, individuals present burnout when they obtain a high score in EE, in combination with a high level of C or a low level of ASE 17 .
ASE is defined as the negative view of oneself.Assess whether the person doubts their ability to perform the academic and practical work.EE is a state of emotional and sometimes physical exhaustion.Those who experience it feel that they cannot give more of themselves and cannot give emotional support to others.This is one of the most obvious manifestations of the syndrome.As for C, it is reflected in indifference, or in a negative attitude of devaluation and loss of interest in studying 14,18 .
The Comprehensive Dental Clinic subject or its equivalent, depending on the corresponding denomination in the study plan, has high practical requirements in a very competitive environment and a difficult interaction with patients, causing stress in the students.This is due to the fact that structured activities imply delivery of work and treatment of patients in short periods of time 3 .According to Vered et al. 10 , it is important to recognize the presence of the initial signs of this syndrome in students, due to the possible negative impact on their health, treatment of patients and academic performance.
Given the above, the objective of this study was to determine the prevalence of burnout syndrome in students attending the Comprehensive Dental Clinic or its equivalent in the Dentistry or Stomatology program of the universities of the La Libertad Region (Peru).In addition, the results are presented according to sex, university and dimensions of the burnout syndrome.The results serve for universities and health authorities to implement preventive measures and/or multidisciplinary therapies aimed at improving the pedagogical aspect, offering treatment to affected students.

Materials and Methods
This study follows an observational, cross-sectional and descriptive design.It was developed from September to November 2018 in the dental centers of the Antenor Orrego Private University (AOPU), National University of Trujillo (NUT), Alas Peruanas University Trujillo Branch (APU) and Los Angeles Catholic University of Chimbote Trujillo Branch (LACUCH), which were the universities that had the Dentistry or Stomatology program in the La Libertad Region (Peru).
Due to the small number of students in the program who were taking the subject in question, the collection of information from the sample population was of a census type, being evaluated those who were present at the time of the application of the survey.Students over 18 years of age enrolled in the programs were included, and students who did not wish to participate, who made smudges and/or did not complete the questionnaire were excluded.
The survey had the approval of the Faculty of Human Medicine and the Research Bioethics Committee of the Antenor Orrego Private University (Resolution # 185-2019-UPAO), in addition to the corresponding authorization from the coordination of the programs of the aforementioned universities.The principles of Helsinki Declaration of the World Medical Association, in its most recent version, and the General Health Law of Peru # 26842, were taken into account.
Before the application of the survey, the purpose of the research was explained to all the students, requesting their participation.Likewise, they were given the informed consent form to read and sign.Finally, the survey was distributed to each student to answer the questions.
The evaluation was carried out through the validated Spanish version of MBI-SS questionnaire, which consists of 15 items, which has been designed to measure the burnout syndrome in students 17,19,20 .This instrument considers that the aforementioned syndrome has three dimensions or subscales: EE, C and ASE 13 .
The data collected was processed automatically in the statistical software SPSS Statistics 22.0 (IBM, Armonk, NY, USA), and then the results are presented in tables according to the objectives set.Absolute frequencies, percentage frequencies and confidence intervals are presented, using double-entry tables.

Results
A total of 154 students were surveyed, who were attending the Comprehensive Dental Clinic or its equivalent in the Dentistry or Stomatology program of the universities of the La Libertad Region.Of these, 85 (55.2%) were female and 69 (44.8%) male, aged between 20 and 45 years (Table 1).In this sense, 66 students from AOPU, 19 from NUT, 18 from APU and 51 from LAUCH were evaluated.Regarding to the prevalence of burnout syndrome, 24.68% of the students presented it.While in Table 2 the prevalence of burnout syndrome is shown, according to university, where the highest percentage (47.37%)was found in the NUT and, the lowest, was presented by the students of the LAUCH (17.65 %).Table 3 shows that the prevalence of burnout syndrome is similar in both sexes.On the other hand, Table 4 indicates the prevalence of burnout syndrome, according to its dimensions, where a greater presence of emotional exhaustion was found (53.90%), while 12.99% of students presented cynicism.

Discussion
Burnout syndrome is due to constant and prolonged exposure to high levels of stress 21 .If it is not treated, it can cause health problems such as insomnia, headaches, cardiovascular and gastrointestinal problems, and depression; likewise, social problems such as mistreatment of relatives and, in the case of health professionals, could affect their patients 16 .
In the present study, it was found that approximately a quarter of the students of the dentistry program who were taking the Comprehensive Dental Clinic subject or equivalent presented burnout.In a similar study carried out by Mafla et al. 22 , it was found that 7% of dentistry students presented burnout, which corroborates, although in a lower percentage, that students who take this subject are prone to presenting this syndrome.Sufia and Latif 16 indicate that it is important to detect this health problem early, because its evolution process is gradual, and it may present aggravation in the future professional [23][24][25] .
It was also found that in the state university (NUT) the prevalence of burnout is higher than in the three other universities.This data coincides with the study by Ghali and Awood 11 , who explains that in private universities there is better availability of clinical facilities and students have fewer problems in taking care of patient treatments, presenting less stress in the process of patient's recruitment, purchase of materials and instruments required in the professional career.In the case of the present study, this difference may also be due to the fact that the dental center of the state university (NUT) is located outside the Trujillo district, making it difficult for patients and students to access and attend.
Regarding the prevalence of burnout, according to gender, it was found that the percentages are similar.These data coincides with the findings of Ghali and Awood 11 and Mafla et al. 22 Ghali and Awood 11 explain that this may be because the students are in the same clinical environment, facing similar obstacles and supporting each other during the semester.
The studies by Atalayin et al. 13 , Sufia and Latif 16 , Ghali and Awood 11 and Collin et al. 3 found, like the present investigation, that students present a high percentage of EE.Sufia and Latif 16 indicate that this may be due to the constant concern of students to meet the theoretical and practical requirements in very limited times.In addition, Ghali and Awood 11 consider that students face problems such as lack of materials, unsuccessful search for patients, and technical problems with work teams.On the other hand, most of the students responded positively in the ASE dimension, showing that they are satisfied with the career, similar data was founded in the present study.
It was also found that the percentage of students with C was low, this result being contrary to what was reported by Sufia and Latif 16 .The difference may be due to the fact that, in some contexts, students have a higher workload and receive mistreatment from part of teachers and administrators 16,21 .
Burnout syndrome has been evaluated in health professionals in different countries of the world.A study carried out in the United States in recent years has found that its prevalence is constantly increasing 26 , being recognized, according to Collin et al. 3 as a "chronic systematic problem that lies fundamentally in the work environment", so its effective treatment requires profound changes such as improving work schedules, increasing tutoring or support for the worker and, if necessary, making changes in the administration.
It is important to highlight that burnout syndrome is a global mental health problem, which is why efforts must be made to detect and treat it as soon as possible 25 .Jin et al. 23 have reported cases of dentists with this syndrome, whose onset may have occurred during their student years.If it is not detected during the undergraduate course, it could have adverse effects on the student's future professional life.In this regard, the study by Meyerson et al. 27 , among young dentistry students and professionals, proposes an early detection using the subscales of the Sensory Processing Sensitivity Questionnaire that may allow the development of strategies to prevent future depletions.
This work provides epidemiological information regarding the mental health of dental students.The conclusions of this study could be extrapolated to the north of the country, since dental programs in Peru have similar educational characteristics and the responsibility to recruit patients to comply with clinical requirements is laid upon the students.
Future longitudinal and correlation studies of this syndrome with sociodemographic characteristics of the students are recommended.In this way, the university authorities of La Libertad region should identify the students who present this health problem to be treated in a timely manner.On the other hand, the Dentistry or Stomatology programs could design a system to recruit patients for clinical practices, guaranteeing a regular flow, in order to help students in their search process, which might avoid the high emotional exhaustion among students.
In conclusion, the results of the present investigation allow us to conclude that the prevalence of burnout syndrome was present in one quarter of the students.In addition, the percentage of students with burnout syndrome was similar in both sexes and emotional exhaustion is the dimension that occurs most frequently.

Table 1 .
Students who attend Odontology Integral Clinic, or its equivalent, in the Dental Program in the universities of La Libertad Region (Peru, 2018), distributed by age, university and sex.Alas Peruanas University Trujillo Branch, ** LACUCH: Los Angeles Catholic University of Chimbote Trujillo Branch, ***NUT: National University of Trujillo, ****AOPU: Antenor Orrego Private University, +CI: Confidence interval.

Table 2 .
Prevalence of the burnout syndrome, according to univerity, in students who attend Odontology Integral Clinic, or its equivalent, in the Dental Program in the universities of La Libertad Region (Peru), 2018.

Table 3 .
Prevalence of the burnout syndrome, according to sex, in students who attend Odontology Integral Clinic, or its equivalent, in the Dental Program in the universities of La Libertad Region (Peru), 2018.

Table 4 .
Prevalence of the burnout syndrome, according to dimensions, in students who attend Odontology Integral Clinic, or its equivalent, in the Dental Program in the universities of La Libertad Region (Peru), 2018.