1 Volume 24 2025 e255389 Original Research Braz J Oral Sci. 2025;24:e255389http://dx.doi.org/10.20396/bjos.v24i00.8675389 1 Department of Health Sciences and Pediatric Dentistry, Faculdade de Odontologia de Piracicaba (FOP), Universidade Estadual de Campinas (UNICAMP), São Paulo, Brazil. 2 Piracicaba Municipal Health Department, Piracicaba, Brazil. 3 Centro Universitário das Faculdades Associadas de Ensino (UNIFAE). São João da Boa Vista, SP, Brazil. 4 School of Social Work, Ariel University, Ariel, Israel. 5 The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Corresponding author: Fábio Luiz Mialhe, PhD Department of Health Sciences and Pediatric Dentistry, Universidade Estadual de Campinas (UNICAMP), Faculdade de Odontologia de Piracicaba (FOP). Piracicaba, São Paulo, Brazil Phone:+55 (19) 98226-1515 Email: mialhe@unicamp.br Editor: Dr. Altair A. Del Bel Cury Received: December 23, 2023 Accepted: March 17, 2024 Factors associated with psychological stress in oral health teams of the public health system during the COVID-19 pandemic: a cross-sectional study Fábio Luiz Mialhe1* , Fernanda Maria Rovai Bado2 , Cristiane Maria da Costa Silva3 , Lais Renata Almeida Cezário1 , Menachem Ben-Ezra4 , Eitan Mijiritsky5 , Maayan Shacham5 The COVID-19 pandemic has impacted the well-being of all healthcare professionals. However, there are still few studies evaluating this aspect in dental professionals. Aim: To identify the contextual and labor-related factors associated with psychological stress in dental professionals working in public healthcare services during the COVID-19 pandemic. Methods: This is an analytical, cross-sectional, and observational study including 96 dental professionals who worked in public services in the municipalities of Piracicaba-SP and Poços de Caldas- MG from October 2021 to January 2022. A self-administered questionnaire was used to collect data on the independent variables [sociodemographic characteristics, health and professional conditions, self-efficacy (Generalized Self-Efficacy Scale – GSE), subjective work overload (Job Demands scale), and thoughts/feelings related to COVID-19] and the outcome (psychological stress - Kessler Psychological Stress Scale-6 - K-6). Simple and multiple logistic regressions were performed using the Stepwise method to test the associations between independent and dependent variables. Results: In multiple regression, professionals who were not in a relationship (OR=4.61; 95% CI: 1.05–20.17) and those with greater subjective burden (OR: 47.18; 95% CI: 5.39–413.21) were more likely to experience psychological stress (p<0.05). Conclusion: Dental professionals working in public health system with greater subjective work overload were more likely to experience greater psychological stress during the COVID-19 pandemic. Keywords: Stress, psychological. Psychological distress. Occupational stress. Oral health. Health services. COVID-19. https://orcid.org/0000-0001-6465-0959 https://orcid.org/0000-0002-7974-5456 https://orcid.org/0000-0002-4987-2403 https://orcid.org/0000-0002-0737-2857 https://orcid.org/0000-0002-7890-2069 https://orcid.org/0000-0002-1661-7529 https://orcid.org/0000-0001-9722-6943 2 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 Introduction In December 2019, Chinese government agencies reported the first cases of COVID-19 disease in the city of Wuhan, and these diagnoses were associated with infection by the SARS-CoV-2 virus1. In early 2020, the disease spread worldwide, leading the World Health Organization (WHO) to classify it, in March 2020, as a global pandemic1. Due to the wide spread of the SARS-CoV-2 virus worldwide, more restrictive rules on territorial mobility were adopted, and social isolation was then encouraged1. The upper airways are the main reservoirs of the SARS-CoV-2 virus, as it causes a respiratory infection. As a result, transmission occurs mainly via direct contact with contaminated people or surfaces, via expelled respiratory droplets by reflexes such as coughs and sneezes, in addition to aerosols2,3. Thus, health professionals, especially those in Dentistry, are among the most exposed to contact with the SARS-CoV-2 virus, as dental procedures generate contaminated aerosols4. Within this context of elevated stress due to a higher risk of death, the mental health of the population and healthcare professionals was greatly affected5-7. Studies that investigated the mental health status of these professionals, including oral health professionals, during the COVID-19 pandemic and post-pandemic, indi- cated associations with psychosocial conditions of stress, depression, anxiety, and episodes of insomnia5,8-10. Despite this, there are still few published studies exploring this phenomenon to date in Dentistry, especially in professionals who work in the Bra- zilian Unified Health System (SUS)8-10. The SUS is a complex and unique healthcare system with 33 years of existence that aims to guarantee comprehensive, universal, and free access to healthcare services for the entire Brazilian population11,12. Formed by a broad healthcare network, the SUS provides individual and collective actions to promote, prevent, and recover health, covering basic, medium, and highly complex care. Among the services offered by SUS, dental care stands out with the implementation of an oral health team in pri- mary care, in addition to the implementation of dental specialty centers and dental emergency centers11,12. Therefore, this study aimed to identify the contextual and labor-related factors asso- ciated with psychological stress in dental professionals working in public health system during the COVID-19 pandemic. We hypothesized that public dental service professionals have a high prevalence of psychological stress which is associated with social determinants, self-efficacy, subjective work overload and thoughts/feelings related to COVID-19. Material and methods Study design and ethical aspects This is an analytical, cross-sectional, and observational study. The research was approved by the Research Ethics Committee of the Piracicaba Dental School – UNI- 3 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 CAMP (CAAE: 52048021.2.0000.5418). This study was conducted in accordance with the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist13. The study included dental professionals [dentists, oral health technicians (OHT), and oral health assistants (OHA)] who worked in public oral health services in the municipalities of Piracicaba-SP and Poços de Caldas-MG from October 2021 to January 2022. According to the Brazilian Institute of Geography and Statistics (IBGE), the munic- ipality of Piracicaba had an estimated population of 410,275 inhabitants in 2021, while the municipality of Poços de Caldas had 169,838 inhabitants14. During the research period, Piracicaba’s public dental service had 30 Family Health Strategy teams (FHS) units and 17 Basic Health Units (BHU), in addition to two Dental Spe- cialty Centers15. In the municipality of Poços de Caldas, the health structure had 36 FHS teams, two BHU, one prison health unit, and one Street Outreach team (Equipe de Consultório na Rua). Regarding FHS, the municipality had 12 family oral health teams and seven primary care oral health teams in the conventional model. In spe- cialized care, the municipality of Poços de Caldas had three medical specialty cen- ters, two Psychosocial Care Centers (CAPS), two Emergency Care Units and one Dental Specialty Center. Data collection was carried out online, using a questionnaire prepared on the Google Forms platform, based on previous studies16,17. To this purpose, an invitation was sent via email to all oral health team members (dentists, oral health technician and an oral health assistant) who worked in the SUS of the two aforementioned municipalities. As an inclusion criterion, the professional should work in the SUS and belong to one of the aforementioned professional categories, regardless of the length of time they have worked in public services. In total, 150 dental professionals from Piracicaba, SP, and 59 professionals from Poços de Caldas, MG, all working in primary care and at the Dental Specialties Center, were invited. Psychological Stress The outcome variable “Psychological Stress” was measured using the Kessler Psy- chological Stress Scale-6 (K-6)18,19. This instrument consists of six items addressing anxiety and depression symptoms that a respondent may have experienced over the last month, namely: feeling “Nervous”; “Hopeless”; “Agitated or restless”; “So depressed that nothing could cheer them up”; “That everything was difficult and required a lot of effort”; “Useless or worthless.” Each item is scored on a 5-point Likert scale (Always; Almost always; Sometimes; Almost never; Never), with higher values considered greater stress18,19. The K618,19 can be scored in two ways (both employing the 5-point Likert scale). Using the 0–4 range for each statement (total score range 0–24), results equal to 13 or above classifies the individual as suffering from psychological stress. Using the 1–5 range for each statement (total score range 6–30), results equal to 19 or above classifies the individual as suffering from psychological stress18,19. In this study the cutoff of 13 points was used. 4 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 Independent Variables Furthermore, other questions were applied to evaluate the participants’ independent sociodemographic variables, health, professional conditions, self-efficacy, subjec- tive work overload, and thoughts/feelings related to COVID-19, based on the study by Shacham et al.17 (2020). Contextual variables The variables linked to sociodemographic characteristics, health and profes- sional conditions were: sex (male/female); age (dichotomized by the median, up to 42 years old/older than 42 years); relationship status (in a serious relationship/not in a relationship); systemic diseases (“Do you suffer from chronic lung disease, moderate to severe asthma, chronic kidney disease, and are you undergoing dialysis or suffering from liver disease/serious heart conditions/conditions that can immu- nocompromise an individual, including cancer treatment/diabetes? – Yes/No”) and dental group (dentist/OHT, OHA). Perceived general self-efficacy Perceived general self-efficacy was assessed using the generalized self-efficacy scale (GSE), which was translated and validated for Brazilian population by Souza and Souza16 (2004). This is a self-administered scale containing 10 statements organized according to people’s self-perception. Each item is rated from 1 to 4 points—1 corresponds to “not at all true” and 4 corresponds to “exactly true”16. The total score ranges from 4 to 44 and, for our study, the sample median value (25 points) was considered to categorize individuals as having low and high levels of perceived generalized self-efficacy. Subjective work overload Subjective work overload was assessed using the scores from the Demands scale (short version), which includes six items assess some aspects of personal stress, namely: “I cannot deal with the contradictory demands placed on me during work”; “During work, the amount of time available for myself is insufficient”; “My work is imposing demands which I do not have the right equipment and resources to meet”; “I leave my job feeling like I have not finished all my tasks”; “I cannot perform my work satisfactorily due to the time available to do it”; “I need to perform simple tasks that prevent me from performing more sophisticated tasks.” Each item is attributed a score ranging from 1 to 5 points—1 means “completely disagree” and 5 corresponds to “completely agree.” The final score ranges 6–30 points17. The higher the value, the greater the subjective work overload. In this study, the pro- fessionals’ scores were dichotomized, based on the sample median, into lowest (≤10) and highest (>10). COVID-19 related variables One of the variables related to COVID-19 was: “Are you afraid of being infected with COVID-19 because of your profession?”, with responses coded as 1) “Not at all”; 2) “Slightly afraid”; 3) “Quite afraid”; and 4) “Very afraid.” Additionally, participants were 5 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 asked: “Do you feel you have acquired sufficient knowledge (via lectures, seminars, information leaflets, etc.) on how to maintain a safe work environment since the onset of the COVID-19 pandemic?”. The response options were dichotomized into insuffi- cient (“not at all” or “slightly” answers) and sufficient (“quite” or “very” answers). Finally, for the following question: “Do you feel that the safety measures adopted today in your workplace are useful for preventing one of your patients transmitting COVID-19 to you?” The answers were dichotomized into less useful (“no” or “somewhat useful” responses) and more useful (“are useful” or “very useful” responses). These questions were based on Shacham et al.17 (2020). Statistical analysis Descriptive analyses of the data were carried out using absolute and relative frequen- cies. Simple and multiple logistic regression models were then adjusted using the Stepwise method, for the outcome “psychological stress.” Based on these models, the crude and adjusted odds ratios were estimated, with the respective 95% confi- dence intervals (95% CI). Model fit was assessed using the Akaike Information Crite- rion (AIC) and the Hosmer–Lemeshow test. The analyses were carried out using the R program20, with a 5% significance level. Results The questionnaires were answered by 96 dental professionals, 64 (66.7%) from Piracicaba and 32 (33.3%) from Poços de Caldas. Table 1 shows that 77.1% (n=74) of participants were females, 66.7% (n=64) were dentists, 33.3% (n=32) were assistants (OHT or OHA) and 11.5% (n=11) had some chronic disease. The mean age of the sample was 42 years (standard deviation=10.7). Notably, although 81.2% (n=78) of respondents stated that they felt they had acquired sufficient knowledge (via lectures, seminars, information leaflets, etc.) on how to maintain a safe work environment since the onset of the COVID-19 pandemic, 62.5% (n=60) were still afraid or very afraid of infecting their family with COVID-19 because of their profession. The average score for this question was 2.11. Furthermore, 40.6% (n=39) of participants reported feeling that the safety measures adopted in their public workplace were not useful or of little use for preventing one of their patients transmitting COVID-19 to them. Regarding the outcome variable, 21 participants (22.7%) were found to suffer from psychological stress (cutoff above 13 points). Table 1 shows that the variables “feels that the safety measures adopted are useful to prevent transmission,” “subjective work overload”, and “general self-efficacy” showed a significant association (OR = 3.06 95% CI: 1.13–8.33; OR= 33.57 95% CI: 4.27–263.94; OR=3.65 95% CI: 1.22–11.01, respectively; p<0.05) with psychological stress when they were studied individually (crude analyses), that is, without considering other con- ditions. The variables “age,” “current relationship status,” “fear of contracting COVID-19 from patients,” and “feels that have acquired sufficient knowledge on how to main- tain a safe work environment is sufficient” presented p<0.20 in individual analyses and were then evaluated in a multiple model associated with the significant variables 6 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 Ta bl e 1. C ru de a nd a dj us te d an al ys es o f i nd ep en de nt v ar ia bl es w ith p sy ch ol og ic al s tre ss (n =9 6) . Ch ar ac te ris tic Ca te go ry n (% ) Ps yc ho lo gi ca l s tr es s Cr ud e O R (9 5% CI ) p- va lu e A dj us te d O R (9 5% CI ) p- va lu e W ith ou t *W ith n (% ) n (% ) Se x M al e 22 (2 2. 9) 19 (1 9. 8) 3 (1 3. 6) Re f - - Fe m al e 74 (7 7. 1) 56 (7 5. 7) 18 (2 3. 4) 2. 04 (0 .5 4– 7. 68 ) 0. 29 43 Ag e (y ea rs ) ≤4 2 50 (5 2. 1) 36 (7 2. 0) 14 (2 8. 0) 2. 17 (0 .7 9– 5. 97 ) 0. 13 51 - - >4 2 46 (4 7. 9) 39 (8 4. 8) 7 (1 5. 2) Re f Ch ro ni c di se as es N o 85 (8 8. 5) 67 (7 8. 8) 18 (2 1. 2) Re f - - Ye s 11 (1 1. 5) 8 (7 2. 7) 3 (2 7. 3) 1. 40 (0 .3 4– 5. 81 ) 0. 64 64 Cu rr en t r el at io ns hi p st at us In a s er io us re la tio ns hi p 75 (7 8. 1) 61 (8 1. 3) 14 (1 8. 7) Re f Re f N ot in a re la tio ns hi p 21 (2 1. 9) 14 (6 6. 7) 7 (3 3. 3) 2. 18 (0 .7 4– 6. 40 ) 0. 15 66 4. 61 (1 .0 5– 20 .1 7) 0. 04 25 Pr of es si on De nt is t 64 (6 6. 7) 51 (7 9. 7) 13 (2 0. 3) Re f - - O H T or O H A 32 (3 3. 3) 24 (7 5. 0) 8 (2 5. 0) 1. 31 (0 .4 8– 3. 57 ) 0. 16 01 0 Af ra id o f c on tra ct in g CO VI D- 19 fr om pa tie nt s N ot a t a ll/ sl ig ht a fra id 36 (3 7. 5) 32 (8 8. 9) 4 (1 1. 1) Re f - - Q ui te a fr ai d/ ve ry a fr ai d 60 (6 2. 5) 43 (7 1. 7) 17 (2 8. 3) 3. 16 (0 .9 7– 10 .3 1) 0. 05 61 Fe el s th at h av e ga in ed s uffi ci en t kn ow le dg e on h ow to m ai nt ai n a sa fe w or k en vi ro nm en t i s su ffi ci en t N ot a t a ll/ sl ig ht ly 18 (1 8. 8) 12 (6 6. 7) 6 (3 3. 3) 2. 10 (0 .6 8– 6. 50 ) 0. 19 82 - - Q ui te /v er y m uc h 78 (8 1. 2) 63 (8 0. 8) 15 (1 9. 2) Re f Fe el s th at th e sa fe ty m ea su re s in th e w or kp la ce a re u se fu l f or p re ve nt in g CO VI D- 19 N ot a t a ll/ sl ig ht ly 39 (4 0. 6) 26 (6 6. 7) 13 (3 3. 3) 3. 06 (1 .1 3– 8. 33 ) 0. 02 84 - - Q ui te /v er y m uc h 57 (5 9. 4) 49 (8 6. 0) 8 (1 4. 0) Re f Su bj ec tiv e ov er lo ad Lo w er v al ue s 48 (5 0. 0) 47 (9 7. 9) 1 (2 .1 ) Re f Re f H ig he r v al ue s 48 (5 0. 0) 28 (5 8. 3) 20 (4 1. 7) 33 .5 7 (4 .2 7– 26 3. 94 ) 0. 00 08 47 .1 8 (5 .3 9– 41 3. 21 ) 0. 00 05 G en er al s el f-e ffi ca cy Lo w er v al ue s 51 (5 3. 1) 35 (6 8. 6) 16 (3 1. 4) 3. 65 (1 .2 2– 11 .0 1) 0. 02 11 - - H ig he r v al ue s 45 (4 6. 9) 40 (8 8. 9) 5 (1 1. 1) Re f * O ut co m e ev en t ( pe rs on w ith p sy ch ol og ic al s tre ss – s co re ≥ 1 3) . R ef : R ef er en ce c at eg or y fo r i nd ep en de nt v ar ia bl es . O R: O dd s ra tio . C I: Co nfi de nc e in te rv al . A IC (e m pt y m od el )= 10 2. 86 ; A IC (fi na l m od el =9 6. 59 ). H os m er –L em es ho w te st p = 0 .4 64 5. 7 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 in the individual analyses. In the multiple model, the variables “current relationship status” and “subjective overload” remained statistically significant with the outcome. Professionals who were not in a relationship (OR=4.61; 95% CI: 1.05–20.17) and had greater subjective burden (OR: 47.18; 95% CI: 5.39–413.21) were found to be more likely to present psychological stress (p<0.05). Discussion This study demonstrated that the perception of greater subjective work overload and not being in a serious relationship were statistically associated with a greater risk of dental professionals experiencing psychological stress. These results were also found by Shacham et al.17 (2020), who investigated the association between factors related to COVID-19 and high levels of psychological stress in a sample of 338 dentists and hygienists working in dental services in Israel during the COVID-19 pandemic. Fur- thermore, a cross-sectional study carried out by Mijiritsky et al.21 (2020) with 11,302 dentists in five countries during the pandemic found high levels of subjective burden and psychological distress among dentists. This result differed among countries, with Italy showing the greatest association. Thus, the association between subjective work overload and psychological stress during the COVID-19 pandemic may be related to the difficulty of healthcare profes- sionals in dealing with the uncertainty of the disease, fear of being infected, changes in the work process related to the pandemic, and social, cultural and environmen- tal factors17,21. García-Batista et al.22 (2021) highlight that strong stressors such as demands for urgency and speed in patient care, as well as the high demand for health- care, hinders the implementation and the use of coping strategies necessary for the health professional’s emotional control. Regarding relationship status, the results were similar to those of other studies23,24 that demonstrated an association between being in a serious relationship and a lower level of psychological stress. These results suggest that people who are in a serious relationship have greater social and psychological support from their partner and/or family, which helps them cope with stressful situations. In this study, 22.7% (n=21) of participants reported suffering from psychological stress, a higher percentage than that found by Shacham et al.17 (2020) (11.5%), which included 338 Israeli dentists and hygienists and was conducted from March to April 2020 (the initial period of the pandemic). These differences may have occurred due to several reasons. Firstly, the sample of our study was exclusively composed of professionals who worked in the public sector, while Shacham’s sam- ple was composed of dental professionals from both public and private sectors. Differences in working conditions and control over occupational risk factors can impact workers’ psychological stress levels25. An interesting finding of our study is that 40.6% of professionals reported feeling that the safety measures adopted in their workplace were not useful or of little use for preventing of one of their patients transmitting COVID-19 to them, which demonstrates that in the respon- dents’ opinion the public workplace is not safe enough to prevent the disease. Another possible reason may be associated to the differences between patients 8 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 treated in private and public services26,27: the latter may present socio-psychologi- cal profiles that affect stress and the professional’s quality of life. Notably, the fact that the percentage of dentists in our sample was greater than that in the afore- mentioned study (66.7% vs. 58.6%) may also explain the outcome. Considering that dentists are those in dental teams who work directly with the patients’ mouth during all care sessions, they are more exposed to biological risks and, therefore, experience greater professional stress. Although psychological stress levels were greater in our sample than in that of Shacham et al.17 (2020), the average score for the question “Are you afraid of being infected by COVID-19 because of your profession?” was lower in the former study than in the latter (2.11 vs 2.88). One of the hypotheses for this fact is that variables other than the COVID-19 pandemic were interfering with the well-being of the pro- fessionals, as observed in other studies. On the other hand, this lower score cor- roborates the epidemiological moment of data collection: in Shacham’s17 study, the collection was carried out from March 30 to April 10, 2020, i.e., at the peak of the pandemic, whereas data collection in our study was carried out at a time when the lowest monthly number of deaths from COVID-19 was observed in 20202. According to the study by Uhlen et al.7 (2021), carried out with more than 1,000 dentists in Norway during the COVID-19 pandemic, the prevention and early treat- ment of psychological disorders in dental professionals are essential for promot- ing personal satisfaction and emotional stability among workers. Furthermore, a systematic review28 that investigated the performance of health professionals and their psychological conditions during the COVID-19 pandemic demonstrated that nine factors were associated with a low performance: depression, anxiety, inadequate social support, occupational stress, decreased productivity, adjust- ments in the workplace, financial concerns associated with changes in income and daily life, fear of transmission, and burnout/fatigue. Taken together, these find- ings demonstrate the importance of implementing strategies aimed at promoting mental health and emotional control in health professionals, which could improve professional performance. In our study, although most professionals responded that they acquired sufficient knowledge for safe dental practice, most participants (62.5%) also reported being more afraid to be infected with COVID-19 because of their profession. These results demonstrate that even with a high level of knowledge and practice, the pandemic neg- atively impacted the mental health of dental professionals worldwide, causing them to develop feelings of fear, anxiety and chronic stress29. This study has some limitations, such as its cross-sectional design, that prevents causality verification, and the application of remote questionnaires, which can gen- erate self-report bias since it is not possible to verify the accuracy of responses30. However, this form of data collection was chosen due to the pandemic scenario, reducing selection bias and allowing the participation of professionals who were most afraid of COVID-19-infection. Moreover, the small sample size may have inter- fered with the strength of association and statistical significance of the analyses. In addition, the absence of more precisely defined criteria for participant selection (for example, exclusion of individuals with pre-existing psychological disorders 9 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 before the pandemic or other unassessed comorbidities) may have introduced bias into the research regarding its impact on psychological stress, potentially influencing the main outcome. Finally, the small sample size is a limitation of this, and we suggest that further studies should be carried out with larger samples. The findings of this study can contribute to the investigation and discussion on the results of future studies about the impact of the COVID-19 pandemic on the psycho- logical stress levels of professionals in the public dentalcare service and its conse- quences on mental and psychological health over time. It is expected that future stud- ies cover larger samples and be conducted in different geographic regions, so that the results of this study can be compared or strengthened and, consequently, generalized. In conclusion, dental professionals from public services who had greater subjective work overload and were not in a serious relationship were more likely to experience high levels of psychological stress. Acknowledgments To all the oral health teams that participated in this research. Funding This research did not receive any type of funding. Conflict of Interest The authors have no conflict of interest to disclose Data availability Datasets related to this article will be available upon request to the corresponding author. Author Contribution Fábio Luiz Mialhe: Conceptualization Resources, Funding acquisition, Supervision, Writing - review & editing. Fernanda Maria Rovai Bado: Methodology, Investigation, Data Curation. Cristiane Maria da Costa Silva: Investigation, Data Curation; Writing - original draft, Writing - review & editing. Lais Renata Almeida Cezário: Writing - original draft, Writing - review & editing. Menachem Ben-Ezra: Methodology, Writing - review & editing. Eitan Mijiritsky: Methodology, Writing - review & editing. Maayan Shacham: Methodology, Writing - review & editing. All authors actively participated in  the manuscript’s findings, revised and approved the final version of the manuscript. References 1. Pan American Health Organization. [WHO says COVID-19 is now characterized as a pandemic]. 2020 Mar 11 [cited 2021 May 10]. Available from: https://www.paho.org/pt/news/11-3-2020-who- characterizes-covid-19-pandemic. Portuguese. 10 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 2. Ministry of Health of Brazil. [Moving average of deaths from Covid-19 has fallen by almost 90% since the peak of the pandemic. 2021 Oct 19 [cited 2023 Sep 24]. Available from: https://www.gov.br/ saude/pt-br/assuntos/noticias/2021/outubro/media-movel-de-obitos-por-covid-19-tem-queda-de- quase-90-desde-o-pico-da-pandemia. Portuguese. 3. Ministry of Health of Brazil. [Coronavirus: Guidelines for dental care in the context of COVID-19]. Brasília-DF; 2021 [cited 2022 Jul 28]. Available from: bvsms.saude.gov.br/bvs/publicacoes/guia_ orientacoes_odontologica_covid19.pdf. Portuguese. 4. Franco JB, Camargo AR, Peres MPSM. [Dental care in the COVID-19 era: recommendations for dental procedures and professionals] Rev Assoc Paul Cir Dent 2020;74(1):18-21. Portuguese. 5. Moreira WC, Sousa AR, Nóbrega MPSS. Mental illness in the general population and health professionals during covid-19: a scoping review. Texto Contexto Enferm. 2020;29:e20200215. doi: 10.1590/1980-265X-TCE-2020-0215. 6. da Silva FCT, Rolim Neto ML. Psychiatric symptomatology associated with depression, anxiety, distress, and insomnia in health professionals working in patients affected by COVID-19: A systematic review with meta-analysis. Prog Neuropsychopharmacol. Biol Psychiatry. 2021 Jan;104:110057. doi: 10.1016/j.pnpbp.2020.110057. 7. Uhlen MM, Ansteinsson VE, Stangvaltaite-Mouhat L, Korzeniewska L, Skudutyte-Rysstad R, Shabestari M, et al. Psychological impact of the COVID-19 pandemic on dental health personnel in Norway. BMC Health Serv Res. 2021 May;21(1):420. doi: 10.1186/s12913-021-06443-y. 8. Gomes P, Vieira W, Daruge R, Recchioni C, Pugliese C, Villafort R, et al. The impact of coronavirus (COVID-19) on dental activities: economic and mental challenges. Res Soc Dev. 2021;10(1):e22310111207. Portuguese. doi: 10.33448/rsd-v10i1.11207. 9. Coutinho J, Boehm FC, Avelino CAS, Aquino MVMB, Gomes TCA, Cavalero C, et al. [Psychological impact of the coronavirus pandemic on dentists in worldwide clinical private practive. Rev Ibero-Am Hum Cien Educ. 2022;8(2):229-46. Portuguese. doi: 10.51891/rease.v8i2.4165. 10. Ruas VB, Santos CA, Carvalho EMN, Santos AF, Santos OS, Teixeira FB. [Evaluation of mental and sleeping disorders in dental surgeons working in Altamira-PA during the COVID-19 pandemic period]. RSD. 2022;11(7):e38411729784. Portuguese. doi: 10.33448/rsd-v11i7.29784. 11. Brazilian Ministry of Health. [Unified Health System – SUS]. Brasilía; 2023 [cited 2023 Nov 30]. Available from: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/sus. Portuguese. 12. Silva ACRM, Molari M. Oral health in primary care through the family health strategy. J Health Sci. 2019;21(2):139-43. doi: 10.17921/2447-8938.2019v21n2p139-143. 13. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4(10):e297. doi: 10.1371/journal.pmed.0040297. 14. Brazilian Institute of Geography and Statistics (IBGE). [Piracicaba and Poços de Caldas: overview] Brasília, DF: IBGE; 2021 [cited 2022 Nov 2]. Available from: https://cidades.ibge.gov.br. 15. Bado FMR, Fonseca DAVD, Cortellazzi KL, Oliveira Júnior AJ, Ambrosano GMB, Mialhe FL. Repercussions of the COVID-19 epidemic on Brazilian National Health System urgent dental care in Piracicaba, Brazil, 2020. Epidemiol Serv Saude. 2021 Nov;30(4):e2021321. doi: 10.1590/S1679-49742021000400023. 16. Souza I, Souza MA. Validação da Escala de Autoeficácia Geral Percebida. Rev Univ Rural. 2004;26(1-2):12-7. 17. Shacham M, Hamama-Raz Y, Kolerman R, Mijiritsky O, Ben-Ezra M, Mijiritsky E. COVID-19 Factors and psychological factors associated with elevated psychological distress among 11 Mialhe et al. Braz J Oral Sci. 2025;24:e255389 dentists and dental hygienists in Israel. Int J Environ Res Public Health. 2020 Apr;17(8):2900. doi: 10.3390/ijerph17082900. 18. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003 Feb;60(2):184-9. doi: 10.1001/archpsyc.60.2.184. 19. Kessler RC. K10 and K6 scales. [cited 2022 Nov 15 ] Available from: https://www.hcp.med.harvard. edu/ncs/k6_scales.php. 20. R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2022. 21. Mijiritsky E, Hamama-Raz Y, Liu F, Datarkar AN, Mangani L, Caplan J, et al. Subjective overload and psychological distress among dentists during COVID-19. Int J Environ Res Public Health. 2020 Jul;17(14):5074. doi: 10.3390/ijerph17145074. 22. García-Batista ZE, Guerra-Peña K, Nouri Kandany V, Marte MI, Garrido LE, Cantisano-Guzmán LM, et al. COVID-19 pandemic and health worker stress: the mediating effect of emotional regulation. PLoS One. 2021 Nov;16(11):e0259013. doi: 10.1371/journal.pone.0259013. 23. Yang H, Ma J. How an epidemic outbreak impacts happiness: factors that worsen (vs. protect) emotional well-being during the coronavirus pandemic. Psychiatry Res. 2020 Jul;289:113045. doi: 10.1016/j.psychres.2020.113045. 24. Sharma A, Chhabra KG, Bhandari SS, Poddar G, Dany SS, Chhabra C, et al. Emotional well-being of dentists and the effect of lockdown during the COVID-19 pandemic: a nationwide study. J Educ Health Promot. 2021 Sep;10:344. doi: 10.4103/jehp.jehp_1337_20. 25. Queensland. Workplace Health and Safety Queensland. Preventing and managing risks to work-related psychological health; 2019 [cited 2023 Sep 24]. Available from: https://www.worksafe. qld.gov.au/__data/assets/pdf_file/0015/52431/managing-work-related-stress1.pdf. 26. Pinto Rda S, de Abreu MH, Vargas AM. Comparing adult users of public and private dental services in the state of Minas Gerais, Brazil. BMC Oral Health. 2014 Aug;14:100. doi: 10.1186/1472-6831-14-100. 27. Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol. 2001 Feb;29(1):73-80. doi: 10.1034/j.1600-0528.2001.00011.x 28. Nowrouzi-Kia B, Sithamparanathan G, Nadesar N, Gohar B, Ott M. Factors associated with work performance and mental health of healthcare workers during pandemics: a systematic review and meta-analysis. J Public Health (Oxf). 2022 Dec;44(4):731-9. doi: 10.1093/pubmed/fdab173. 29. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020 Apr;17(8):2821. doi: 10.3390/ijerph17082821. 30. Gava G, Fisher AD, Alvisi S, Mancini I, Franceschelli A, Seracchioli R, et al. Mental health and endocrine telemedicine consultations in transgender subjects during the COVID-19 outbreak in Italy: a cross-sectional web-based survey. J Sex Med. 2021 May;18(5):900-7. doi: 10.1016/j.jsxm.2021.03.009.