1 Volume 24 2025 e257207 Original Research Braz J Oral Sci. 2025;24:e257207http://dx.doi.org/10.20396/bjos.v24i00.8677207 1 Department of Social Dentistry, School of Dentistry, São Paulo State University (Unesp), Araraquara, São Paulo Brazil. 2 Department of Preventive and Social Dentistry, Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil. Corresponding author: Luis Eduardo Genaro Department of Preventive and Social Dentistry Araçatuba Dental School, São Paulo State University, Araçatuba, Brazil Email: luis-genaro@outlook.com Editor: Dr. Altair A. Del Bel Cury Received: July 15, 2024 Accepted: March 05, 2025 Stress and minor mental disorders in undergraduate dental students: a cross-sectional study Julia Tiemy Michigami1 , Isabela Antunes de Medeiros1 , Luis Eduardo Genaro2* , Elaine Pereira da Silva Tagliaferro1 , Silvio Rocha Corrêa da Silva1 , Aylton Valsecki Júnior1 , Fernanda Lopez Rosell1 This study aimed to analyze the occurrence of stress and minor mental disorders (MMD) among dental students. Participants included students in the pre-clinical stage (N=123) and clinical stage (N=169) of the dental program. Data collection was carried out using sociodemographic data, Dental Environmental Stress (DES) and Self-Reporting Questionnaire (SRQ-20) to evaluate the minor mental disorders (DMM). Analysis was conducted using the Mann-Whitney test, Fisher’s exact test, and logistic regression with a significance level of 5%. The overall mean for stressors was 2.7, indicating a range between “Mildly Stressful” and “Moderately Stressful,” with higher levels observed in the clinical stage (2.8) and among women (2.9). The main stressors were “Exams and grades” (pre-clinical - 3.7, clinical - 3.9; p=0.0314), “Fear of failing a subject or losing the year” (pre-clinical - 3.6, clinical - 3.7; p=0.7596), “Completing graduation requirements” (pre-clinical - 3.4, clinical - 3.6; p=0.1092), and “Lack of time for relaxation or leisure” (pre-clinical - 3.3, clinical - 3.6; p=0.0037). The overall prevalence of MMD was 78.5%, with higher rates observed in the clinical stage (82.2%) and among women (81.6%). Of the variables in the regression analysis, two remained significant: “Difficulties at work” (p=0.001) and “Loss of interest in things” (p=0.033). The environment experienced by the participants in this study presents stressors, with a high prevalence of suspected MMD among female students in both stages of the dental program. Keywords: Occupational stress. Mental disorders. Students, dental. https://orcid.org/0009-0006-9354-1341 https://orcid.org/0009-0001-4035-209X https://orcid.org/0000-0003-4206-2974 https://orcid.org/0000-0001-6225-6915 https://orcid.org/0000-0002-0227-8896 https://orcid.org/0000-0002-1776-0925 https://orcid.org/0000-0002-6270-9168 2 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Introduction Admission to the University constitutes a very significant transition process in the stu- dent’s life. In this new stage, there is a need to adapt to a new university context full of novelties and challenges. This set of factors, called stressors, has a direct impact on the quality of life of individuals, which can alter psychological functioning and cause disorders that compromise the health and academic performance of students1-4. Stress can be defined as the state caused by the perception of stimuli capable of generating emotional arousal that, by disturbing homeostasis, result in a process of adaptation, thus generating systemic manifestations and physiological and psycho- logical disorders. The term stressor, in turn, defines the event or stimulus that will drive the stress1,2. The way the individual evaluates and deals with the stressful situa- tion is related to some moderating agents, such as personality, social support, educa- tional level, etc. When the body’s ability to maintain homeostasis is overtaken by the stressor, then the diseases resulting from stress arise². In this context, we can say that students are exposed to several stressors within the academic environment, such as knowledge overload, personal and teacher charges, tests and grades, among others. Among dental students, stress can also arise due to laboratory and clinical training, which require, in addition to theoretical competencies, the development of manual and interpersonal skills with patients³. During this pro- cess, we can say that students are negatively affected by stress, which has numerous consequences for their academic performance and psychosocial well-being4. Minor mental disorders (MMD) represent less severe and more frequent mental dis- orders. Symptoms include memory alterations, difficulty concentrating and making decisions, insomnia, irritability and fatigue, as well as somatic complaints (headache, lack of appetite, tremors, gastrointestinal symptoms, among others)5. These symp- toms can impact relationships, quality of life and compromise performance in daily activities, in addition to being substrates for the development of more severe disor- ders6. It is estimated that 15 to 25% of university students present some psychic disor- der during their academic training, as it constitutes a phase of great changes in the subject’s life7. In Brazil, the prevalence rates of minor mental disorders in academics ranged from 25%8 to 58%9. According to the report Fonaprace10, in a sample of 939,604 students from IFES (Fed- eral Institutions of Higher Education), 79.8% of the students reported experiencing emotional difficulties in the last twelve months. The emotional difficulty most reported by the students was anxiety (58.36%) followed by discouragement/unwillingness to do things, with a frequency of 44.72%. Of the total students surveyed, 30.45% reported having already sought psychological care. Students in the health area, when compared to students in other areas, are more vul- nerable to psychological problems due to the demands to which they are submitted11,12. Cherchiari et al.8 investigated the mental health of students from different courses. The total prevalence of MMR in this population was 25%, with nursing students being 3 Michigami et al. Braz J Oral Sci. 2025;24:e257207 the most affected (34%). Facundes and Ludermir13 conducted a similar study, proving that there is a higher incidence of these disorders in students in the health area, with a general rate of 34.1%, with a predominance among medical students (42.6%). In another study14 with medical, dental and nursing students, they found a general prev- alence for the same disorders of 33.7%. Since the university environment has numerous stressors capable of causing import- ant changes in the body, including putting at risk the mental health of students, the present study proposed to identify the occurrence of stress and minor mental disor- ders in students of the Undergraduate Course in Dentistry in a certain college in Brazil. Material and Method Study design and sample selection It was a descriptive, cross-sectional and exploratory study. The sample design in this study was non-probabilistic. The sample was composed of students enrolled in the Undergraduate Course in Dentistry of the School of Dentistry of Araraquara – UNESP in the Pre-Clinical phase (N = 123) (belonging to the 1st to the 4th semester), who attend pre-clinical disciplines of a theoretical and practical nature (laboratory), but do not yet have specific clinical and academic activities enrolled in the Clinical Stage (N = 169) (belonging to the 5th to the 10th semester, they take courses more focused on learning clinical practice and patient care, in an increasing degree of technical-scien- tific complexity. The study was approved by the Human Research Ethics Committee of the Universidade Estadual Paulista (UNESP) of the Faculdade de Odontologia de Araraquara (registration number CAAE: 16161419.0.0000.5416) Data collection Socio-demographic data: Used to obtain data related to the student’s profile. This questionnaire was developed by Sangiorgio et al.15 and adapted by the authors of the present study, reducing the number of questions. Dental Environmental Stress (DES) Used to identify and quantify specific stressors in dental students. This questionnaire was translated and validated into Portuguese by Sangiorgio et al.15, with the name of Stress in the Dental Environment (OAS). Composed of 36 items answered by the fol- lowing scale: 0 (not applicable), 1 (non-stressful), 2 (slightly stressful), 3 (moderately stressful) and 4 (very stressful). The items are divided into domains for a better analy- sis of the data, namely: “Academic Performance”, “University Relationship”, “Responsi- bility with patients”, “Professional Difficulties” and “Personal and Institutional Factors”. Self-Reporting Questionnaire (SRQ-20) Used to identify the presence of anxious, depressive and psychosomatic symptoms. This instrument was developed with the objective of evaluating minor mental disor- ders (DMM) in populations. It is intended for the detection of symptoms, that is, it 4 Michigami et al. Braz J Oral Sci. 2025;24:e257207 suggests a level of suspicion (presence/absence) of some mental disorder, but does not discriminate a specific diagnosis; thus, it assesses whether there is any disorder, but does not offer a diagnosis of the type of existing disorder. Because of this screen- ing character, it is very suitable for population studies, being very useful for a first classification of possible cases and non-cases. This instrument was translated into Portuguese by Busnello et al.16 and is recommended by the World Health Organization to screen for psychiatric disorders in primary health care centers The questionnaire consists of 20 questions with “yes” or “no” answers, four questions about physical symptoms and 16 about psychoemotional disorders. Each “yes” answer is assigned one point, resulting in a final score ranging from 0 to 20 points. When analyzing the SRQ-20, different cutoff points were used for each sex. Men with a score ≤ 5 and women with a score ≤ 7 were classified as “not suspected of MMD” and men with a score ≥ 6 and women with a score ≥ 8 were classified as “suspected of MMD”. The questionnaires were prepared in “Google Forms” and made available through a link to be answered online. To prevent people who are strangers to the study sample from having access to the questionnaire, each student received in their institutional e-mail the link to access the questionnaire, being the exclusive access through the link sent to each participant. Data analysis The collected data were entered into spreadsheets and evaluated using the SPSS ver- sion 17.0 program, and the results were expressed in tables with the frequency distri- bution in absolute and percentage numbers. After obtaining the prevalence of stress and minor mental disorders, tests of association between the dependent variables and the independent variables were performed using the chi-square test with a signif- icance level of 5% and logistic regression. Results Socio-demographic data The participating students were mostly women (74.7%), single (98.6%) and were, on average, 21.5 years old. The majority (44.7%) live with other people, 31.1% live alone, 19.1% live with their parents or relatives and 5.1% live in other types of individual/ collective housing, and no participant reported living with a spouse and/or children. Among the participants of this study, 72.9% declared having moved to another city to attend university, 15.1% already lived in Araraquara and 12% claimed to have changed state. Most of the students declared to be in the same entrance class (90.4%) and not to have any failure (87.0%). Dental Environmental Stress (DES) The overall mean of the stressors among the participants was 2.7 (standard deviation 1.3), being located between Mild Stressful and Moderately Stressful. The mean among the stressors was higher among the students of the clinical stage, with a mean of 2.9 (standard deviation 1.2). The preclinical stage presented a mean 5 Michigami et al. Braz J Oral Sci. 2025;24:e257207 slightly below this value, with 2.4 (standard deviation 1.4), values also considered between Mild Stressful and Moderately Stressful. Table 1 shows the means of the stressors according to the domains, with the division of the students into the preclinical and clinical stages. Table 1. Mean and standard deviation of the level of stressors of the questionnaire “DES”, according to the Domains, in the pre-clinical and clinical stages of the students of the Dentistry Course. Domains/Stressor Factor Steps/Level/Standard Deviation p Preclinical Clinic Academic Performance Amount of work required in the classroom 3.0 (0.9) 2.9 (0.9) 0.4196 Difficulties in the classroom 2.8 (0.9) 2.9 (1.0) 0.0960 Exams and grades 3.7 (0.6) 3.9 (0.5) 0.0314* Environment created by the faculty 2.7 (1.0) 3.6 (0.5) <0.0001* Receive criticism of the work done 2.3 (1.2) 2.7 (1.0) 0.0056* Lack of time to relax or for leisure 3.3 (0.9) 3.6 (0.7) 0.0037* Complete the requirements for graduation 3.4 (0.9) 3.6 (0.8) 0.1092 Reconciling personal life with college routines 3.4 (0.7) 3.5 (0.8) 0.1072 Fear of failing a discipline 3.6 (0.9) 3.7 (0.7) 0.7596 Lack of time to do the required jobs 3.3 (0.8) 3.4 (0.8) 0.0628 University Relationship Competitiveness by grade 3.1 (1.2) 2.8 (1.3) 0.0283* Interactions with people of the opposite sex 1.5 (0.9) 1.5 (1.0) 0.8925 Amount of academic dishonesty 1.9 (1.3) 2.1 (1.3) 0.0984 Lack of family atmosphere during college 1.7 (1,4) 1.9 (1.5) 0.5047 Discriminatory attitudes towards female students 2.2 (1.4) 2.6 (1.4) 0.0511 Conflict with the family over the future of the profession 1.5 (1.1) 1.7 (1.3) 0.1829 Discrimination due to social status or ethnic group 1.7 (1.5) 1.9 (1.5) 0.3070 Discriminatory attitudes towards homosexual dental students 1.9 (1.6) 2.3 (1.7) 0.0640 Responsibility to patients Lack of cooperation of patients in the care they must take at home 0.9 (1.2) 2.6 (0.8) <0.0001* Responsibility for the care of the patient’s health in an integral way 1.3 (1.4) 2.7 (1.0) <0.0001* Delay or lack of patients in appointments 0.9 (1.2) 2.5 (1.0) <0.0001* Perform treatments in patients with mouths without proper hygiene 1.0 (1.3) 2.2 (1.0) <0.0001* Professional Difficulties Difficulty learning clinical procedures 1.9 (1.5) 3.0 (1.0) <0.0001* Difficulty learning manual skills in the preclinical stage 1.8 (1.5) 3.0 (1.0) <0.0001* Lack of confidence in being a successful dental student 3.2 (1.0) 3.4 (0.9) 0.0607 Continue 6 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Continuation Lack of self-confidence in being a successful dentist 3.2 (1.0) 3.5 (0.8) 0.0045* Insecurity about the professional future 3.4 (0.9) 3.7 (0.7) 0.0039* Fear of being unable to recover in studies 3.5 (0.9) 3.5 (0.9) 0.7979 Personal and Institutional Factors Rules and regulations of the dental school 2.0 (1.0) 2.4 (1.0) 0.0001* Differences between college expectations and reality 2.7 (1.1) 3.2 (0.9) 0.0001* Lack of participation in college decision-making processes 2.3 (1.1) 2.8 (1.0) 0.0003* Financial responsibilities 3.2 (1.0) 3.5 (0.8) <0.0001* Consider joining another workspace 1.7 (1.3) 2.1 (1.6) 0.0160* Difficulties in making marital commitments due to dental school 1.4 (1.5) 1.4 (1.5) 0.9686 Personal physical health 2.9 (1.0) 3.2 (1.0) 0.0044* Incompatibility between evaluations of work between different teachers 2.6 (1.3) 3.4 (0.9) <0.0001* *Statistically significant, Mann Whitney test, p<0.05 In the “Academic performance” domain, the highest averages among the stress- ors in the preclinical and clinical stages, respectively, were: “Tests and grades” (3.7 and 3.9), “Fear of failing a subject or losing the year” (3.6 and 3.7), “Completing the requirements for graduation” (3.4 and 3.6), “Lack of time to relax or for leisure” (3.3 and 3.6), whereas levels between 3 and 4 are categorized as moderately and very stressful. It is noted that the greatest difference between the preclinical and clinical means was in the factor “Environment created by the faculty” (2.7 and 3.6), that is, from slightly to moderately stressful. In the “University Relationship” domain, the factor “Competitiveness by grade” stands out, where the average in the students of the pre-clinical stage was 3.1 and in the clinical stage of 2.8, being located at the level Mild and Moderately Stressful, and this being the only factor with statistically significant difference. The lowest average of the group was 1.5 for both stages in the factor “Interactions with people of the opposite sex”. In the domain “Responsibilities with patients”, all questions presented a statistically significant difference, ranging from non-stressful to moderately stressful, with higher mean values in the clinical stage. In descending order (pre-clinical and clinical respec- tively) we have: “Responsibility for the health care of the patient in an integral way” (1.3 and 2.7), “Lack of cooperation of patients in the care they should take at home” (0.9 and 2.6), “Delay or lack of patients in consultations” (0.9 and 2.5), “Perform treatments in patients with mouths without adequate hygiene” (1.0 and 2.2). This is due to the difference in experiences found by the two groups, since the preclinical stage has little or no contact with patients, while the clinical stage deals with them more frequently in their routine in college. The fourth domain “Professional difficulties”, covers issues of self-confidence of the student, both about their expectations and possible frustrations in the profession 7 Michigami et al. Braz J Oral Sci. 2025;24:e257207 and in graduation. The highest averages were the following factors: “Insecurity about the professional future” (3.4 pre-clinical and 3.7 clinical) and “Fear of being unable to recover if I fall behind in studies” (3.5 for both groups), categorized as Moderately Stressful. All factors were statistically significant, except for “Lack of confidence in being a successful dental student.” Two factors stand out for the difference in mean in the populations, they are: “Difficulty in learning clinical procedures” (1.9 and 3.0) (p<0.0001) “Difficulty in learning precision manual skills required in preclinical and lab- oratory work” (1.8 and 3.0) (p<0.0001) In the last domain, “Personal and Institutional Factors” it is observed that, once again, the mean values of the clinical stage are higher than the values of the preclinical stage and all presented statistically significant difference, except for a single ques- tion (“Difficulties in assuming marital commitments (living together, engagement, marriage) due to the dentistry course”). The most prominent factor was “Financial Responsibilities” with an average of 3.2 preclinical and 3.5 clinical, categorized as Moderately Stressful. An analysis of stressors in relation to gender was also performed, with the same domains. The mean of the female gender was the highest with 2.8 (standard deviation 1.3), while the male gender obtained a mean of 2.4 (standard deviation 1.4), values considered between Mild Stressful and Moderately Stressful. The mean values of the questions related to stressors, according to gender, are shown in Table 2. Table 2. Mean and standard deviation of the level of stressors of the questionnaire “DES”, according to the Domains, in the female and male gender of the students of the Dentistry Course. Araraquara, 2019. Domains/Stressor Factor Gender/Level/Standard Deviation p Feminine Masculine Academic Performance Amount of work required in the classroom 3.0 (0.9) 2.7 (0.8) 0.0047* Difficulties in the classroom 2.9 (0.9) 2.6 (1.0) 0.0349* Exams and grades 3.8 (0.4) 3.6 (0.7) 0.0696 Environment created by the faculty 3.2 (0.9) 2.6 (1.0) 0.0001* Receive criticism of the work done 2.7 (1.0) 2.1 (1.0) 0.0004* Lack of time to relax or for leisure 3.6 (0.8) 3.4 (0.9) 0.1058 Complete the requirements for graduation 3.6 (0.8) 3.3 (1.0) 0.0350* Reconciling personal life with college routines 3.6 (0.7) 3.2 (0.9) <0.0001* Fear of failing a discipline 3.7 (0.7) 3.4 (1.0) 0.1397 Lack of time to do the required jobs 3.5 (0.8) 3.1 (0.8) 0.0043* University Relationship Competitiveness by grade 3.0 (1.2) 2.7 (1.4) 0.0697 Interactions with people of the opposite sex 1.6 (1.0) 1.2 (0.9) 0.0069* Continue 8 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Continuation Amount of academic dishonesty 2.0 (1.3) 2.0 (1.5) 0.9149 Lack of family atmosphere during college 1.9 (1.5) 1.4 (1.2) 0.0112* Discriminatory attitudes towards female students 2.7 (1.2) 1.7 (1.7) <0.0001* Conflict with the family over the future of the profession 1.6 (1.2) 1.5 (1.2) 0.3960 Discrimination due to social status or ethnic group 1.7 (1.5) 1.9 (1.6) 0.5798 Discriminatory attitudes towards homosexual dental students 2.3 (1.6) 1.7 (1.6) 0.0200* Responsibility to patients Lack of cooperation of patients in the care they must take at home 2.0 (1.3) 1.7 (1.4) 0.1500 Responsibility for the care of the patient’s health in an integral way 2.3 (1.4) 1.7 (1.3) 0.0039* Delay or lack of patients in appointments 1.9 (1.3) 1.7 (1.3) 0.2463 Perform treatments in patients with mouths without proper hygiene 1.8 (1.3) 1.5 (1.3) 0.0523 Professional Difficulties Difficulty learning clinical procedures 2.7 (1.4) 2.1 (1.2) 0.0003* Difficulty learning manual skills in the preclinical stage 2.7 (1.4) 1.9 (1.3) <0.0001* Lack of confidence in being a successful dental student 3.4 (0.9) 3.0 (1.0) 0.0006* Lack of self-confidence in being a successful dentist 3.5 (0.9) 2.9 (1.0) <0.0001* Insecurity about the professional future 3.7 (0.7) 3.2 (1.0) 0.0012* Fear of being unable to recover in studies 3.6 (0.8) 3.2 (1.0) 0.0097* Personal and Institutional Factors Rules and regulations of the dental school 2.3 (1.0) 1.9 (0.9) 0.0056* Differences between college expectations and reality 3.1 (0.9) 2.5 (1.1) 0.0002* Lack of participation in college decision-making processes 2.7 (1.1) 2.3 (1.2) 0.0127* Financial responsibilities 3.5 (0.8) 2.9 (1.0) <0.0001* Consider joining another workspace 2.0 (1.5) 1.6 (1.4) 0.0290* Difficulties in making marital commitments due to dental school 1.5 (1.5) 1.2 (1.4) 0.1821 Personal physical health 3.2 (1.0) 2.8 (1.0) 0.0030* Incompatibility between evaluations of work between different teachers 3.1 (1.1) 2.8 (1.3) 0.0611 *Statistically significant, Mann Whitney test, p<0.05. In the “Academic Performance” domain, all stressful factors presented higher averages in the female gender, with the factor “Exams and grades” standing out with the highest averages in each group (female=3.8 and male=3.6). Thus, a sta- tistical difference is observed in most factors, listed in ascending order of signifi- cance: “Meeting graduation requirements (Grades/Clinical production/Internship)” (p=0.0350), “Difficulties in the classroom” (p=0.0349), “Amount of work required in the classroom” (p=0.0047), “Lack of time to complete school assignments” (p=0.0043), “Receiving criticism for work done” (p=0.0004), “Environment cre- ated by faculty members” (p=0.0001), and “Balancing personal life with college 9 Michigami et al. Braz J Oral Sci. 2025;24:e257207 routines” (p=<0.0001). In this domain, all values are considered between Mildly Stressful and Moderately Stressful. In the “University Relationships” domain, the highest averages were found in the fac- tor “Competition for grades” (3.0 for females and 2.7 for males), ranging from Mildly Stressful to Moderately Stressful. Only one average from the male gender (1.9) was higher than that of the female gender (1.7) in the factor “Discrimination based on race, social status, or ethnic group.” Regarding statistical differences, the factors in ascending order of significance were: “Discriminatory attitudes of the university com- munity towards female dental students” (p=<0.0001), “Discriminatory attitudes of the university community towards homosexual dental students” (p=0.0200), “Lack of a family atmosphere in student residences/fraternities during college” (p=0.0112), and “Interactions with individuals of the opposite sex” (p=0.0069). In the “Responsibility towards Patients” domain, women demonstrated being more affected than men, particularly in the factor “Responsibility for comprehensive patient care” (2.3 for females and 1.7 for males), ranging from Not Stressful to Mildly Stress- ful. This was also the only factor with a statistically significant difference. “Professional Difficulties,” all the averages for the female gender were also higher than those for the male gender. Additionally, all the factors showed statistically significant differences, in increasing order: “Fear of being unable to recover if I fall behind in my studies” (p=0.0097), “Insecurity about the professional future” (p=0.0012), “Lack of confidence in being a successful dentistry student” (p=0.0006), “Difficulty in learning clinical procedures” (p=0.0003), “Difficulty in acquiring precise manual skills required in pre-clinical and laboratory work,” and “Lack of self-confidence in being a success- ful dentist” (p=<0.0001). In this domain, all the values are considered to be between non-stressful and moderately stressful. “Personal and Institutional Factors,” once again, all the averages for the female gen- der were higher than those for the male gender, with the highest being the factor “Financial responsibilities” (3.5 for females and 2.9 for males). Six out of the eight factors in this domain showed statistically significant differences, in increasing order: “Financial responsibilities” (p=<0.0001), “Personal physical health” (p=0.0030), “Rules and regulations of the dental college” (p=0.0056), “Lack of participation in college decision-making processes” (p=0.0127), and “Considering entering another field of work” (p=0.0290). In this domain, all the values range from non-stressful to moderately stressful. Self-Reporting Questionnaire (SRQ-20) Regarding mental health, 78.5% of the students obtained scores that classified them as “suspected of Mental Health Disorders” (Table 3). The study found a higher prev- alence among Clinical stage students (82.2%), females (81.6%), those aged up to 21 years (81.2%), living with other people (83.2%), having relocated to a different city/ state (78.9%), being in the same admission class (82.1%), and having experienced academic failure (78.9%). The only variable that showed statistical significance (p<0.05) for suspected mental disorders was female gender (81.6%). 10 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Table 3. Distribution of the frequency of suspected cases of minor mental disorders (MMD) according to sociodemographic variables among students of the Dentistry Course.  Variables/Frequency n % % MMD p Period Preclinical 123 42.1 73.2 0.0833 Clinic 169 57.9 82.2 Age Up to 21 years 154 52.7 81.2 0.2031 22 or + years 138 47.3 74.6 Gender Female 218 74.7 81.6 0.0325* Male 74 25.3 68.9 Housing condition With other people 121 42.8 83.2 0.4484 Other types 15 5.3 53.3 Parents or relatives 56 19.8 76.8 Alone 91 32.1 75.8 Changed city/state No 44 15.1 72.7 0.4288 Yes 247 84.9 78.9 Same class No 28 9.6 77.7 0.8101 Yes 265 90.4 82.1 He was reproachful No 255 87.0 67.9 0.9999 Yes 38 13.0 78.9 Legend: n= absolute number of participating students *p<0.05 - statistically significant. Fischer’s exact test. The frequency of minor mental disorders and their association with socio-demo- graphic data can be found in Table 3. The questions of the Self-Reporting Questionnaire (SRQ-20) were evaluated, and the frequencies of the answers according to the Preclinical and Clinical stages are shown in Table 4. 11 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Table 4. Distribution of the frequency of the variables of the questionnaire “SRQ-20”, according to the division of students in the Preclinical and Clinical stages of the Dentistry Course. Variables Period Preclinical Clinic pYes No  Yes No n  % n  % n  % n  % Frequent headache 59 48.0 64 52.0 94 55.3 76 44.7 0.2370 Lack of appetite 28 22.7 95 77.2 39 22.9 131 77.1 1.0000 Difficulty sleeping 80 65.0 43 35.0 116 68.2 54 31.8 0.6155 Scares easily 56 45.5 67 54.5 91 53.5 79 46.5 0.1938 Feels nervous 111 90.2 12 9.80 156 91.8 14 8.20 0.6810 Tremors in the hand 47 38.2 76 61.8 68 40.0 102 60.0 0.8088 Poor digestion 48 39.0 75 61.0 75 44.1 95 55.9 0.4031 Difficulty thinking clearly 63 51.2 60 48.8 97 57.1 73 42.9 0.3431 Feel sadness lately 80 65.0 43 35.0 133 78.2 37 21.8 0.0165* Cries more than usual 51 41.5 72 58.5 96 56.5 74 43.5 0.0130* Difficulty in activities with satisfaction 85 69.1 38 30.8 137 80.6 33 19.4 0.0273* Difficulty making decisions 82 66.7 41 33.3 119 70.0 51 30.0 0.6102 Difficulties in the service 42 34.2 81 65.8 98 58.0 71 42.0 <0.0001* Unable to play a useful role 34 27.6 89 72.4 64 37.6 106 62.4 0.0800 Lost interest in things 62 50.4 61 49.6 116 68.2 54 31.8 0.0024* Feels a useless person 48 39.0 75 61.0 65 38.2 105 61.8 0.9038 He had the idea to end his life 12 9.80 111 90.2 17 10.0 153 90.0 1.0000 Feels tired all the time 87 71.3 35 28.7 144 84.7 26 15.3 0.0083* Gets tired easily 93 75.6 30 24.4 135 79.4 35 20.6 0.4776 Unpleasant sensations in the stomach 66 53.6 57 46.4 90 52.9 80 47.1 0.9062 Legend: n= absolute number of responses *p<0.05 - statistically significant. Fischer’s exact test. Of the 20 questions of the questionnaire, only 6 showed a statistically significant dif- ference (p<0.05) between the groups, namely: “Feel sad lately” (p=0.0165), “Cry more than usual” (p=0.0130), “Difficulty to perform activities with satisfaction” (p=0.0273), “Difficulties in the service” (p<0.0001), “Lost interest in things” (p=0.0024) and “Feel tired all the time” (p=0.0083). In more than half of the questionnaire (14 questions) there was no statistical differ- ence between the groups. In all these items, the students of the clinic always answered more yes than those of the pre-clinic, indicating that they were more affected. Next, logistic regression analysis of the variables that presented statistical signifi- cance in the SRQ-20 was performed (Table 5). 12 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Table 5. Regression analysis of the variables that presented statistical significance of the questionnaire “SRQ-20”, according to the division of students in the Preclinical and Clinical stages of the Dentistry Course. Araraquara, 2019. Questionnaire variables “SRQ-20” Model β P Feels sad lately 0,115 0,165 Cries more than usual 0,076 0,277 Difficulty performing activities with satisfaction 0,017 0,851 Difficulties in the service 0,245 <0.0001* Lost interest in things 0,168 0,033* Feels tired all the time 0,117 0,210 Adjusted R2  0,073 P 0,002 *p<0.05 - statistically significant. Logistic Regression. Of the 6 variables placed in the regression, only 2 remained significant, being “Difficul- ties in the service” (p = <0,001) and “Lost interest in things” (p = 0,033). Both variables were higher in the students of the clinical stage, indicating that they are more affected. Discussion The obtained data corroborate with studies found in the literature, especially regarding the high prevalence among females17-22. The overall average of stressors among the participants was 2.7, ranging between Mildly Stressful and Moderately Stressful. This value is higher when compared to other studies, such as the study by Uraz et al.18, which found an average of 2.5; Abu-Ghazaleh et al.20 in Jordan reported 2.40, and Morse and Dravo22 observed an overall average of 2.52. In this study, it was observed that the main stressors present in the academic environ- ment are consistent with previous studies, including “Exams and grades,” “Fear of failing a subject or repeating the year,” and “Lack of time to relax or engage in leisure activities.” Therefore, it can be observed that this pattern is consistent in other dental universities in Brazil and other countries18-20,22. Considering the academic stage in which the students were classified, the average of stressors was higher among participants in the Clinical stage, with an average stressor score of 2.9. This value is higher than that found in India (2.4)20, Florianópo- lis (2.61)19, and Jordan (2.7)18. The Pre-clinical stage showed a slightly lower aver- age, with a score of 2.4, which is similar to a study conducted at a university in Florianópolis (2.42)19. In the pre-clinical stage, the greatest concerns were “Exams and grades” (3.7), “Fear of failing a subject or losing the year” (3.6), and “Fear of being unable to catch up if I fall behind in my studies” (3.5). During this period, students are more concerned with issues related to the required theoretical work, grades, and evaluations. 13 Michigami et al. Braz J Oral Sci. 2025;24:e257207 In the clinical stage, a higher average stress level was observed compared to the pre-clinical stage, as well as a higher average for its main stressors. This is also observed in other studies17-19,21,23. In this particular stage, in addition to the concerns that afflict students regarding grades, exams, and failures, new factors related to clin- ical practice also arise. For these students, the stressors continued to be “Exams and grades” (3.9) and “Fear of failing a subject or losing the year” (3.7), followed by “Completing gradua- tion requirements” (3.6) and “Lack of time to relax or for leisure” (3.6), and in addi- tion to these, we have “Insecurity about future professional prospects” (3.7). The increased stress in this stage can be explained by the pressure students feel to per- form multiple clinical procedures in various dental specialties while also succeeding in theoretical subjects20. Thus, we can highlight that some stressors remain and become more significant as the academic stages progress, such as “Exams and grades” and “Fear of failing a subject or losing the year”. This can be explained by the characteristics of dental edu- cation, which gradually evolves, increasing the complexity and demands in theoretical, laboratory, and clinical fields. Furthermore, previous studies21,24 have observed that anxiety about the future increases each year, reaching its peak in the final year of graduation, which can be explained by insecurity about entering the job market and the fear of unemployment after graduation. We can observe factors with a statistically significant difference between stages, such as the question of “Environment created by the faculty”, where the difference is quite high (p=<0.0001). This finding is consistent with other studies, which assert that clinical-year students consider educational environment-related factors more stress- ful than pre-clinical students17,19,22. This fact can also be explained by greater interac- tion between students and faculty in the clinic, as well as the fear of feeling humiliated when criticized by a professor in front of a patient21. Lastly, when evaluating the same domains in terms of gender, the average for females was higher (2.8) than for males (2.4). This result is consistent with findings by other authors18,25-27 and differs from what was found by Kumar et al.17, whose study showed a significant difference in stress perception between genders, with a preference for males. Studies suggest that female dental students feel more pressure to succeed in a male-dominated profession, and they perceive the pressure and competition pres- ent in dental education as particularly stressful23,28,29. The overall prevalence of mental health disorders (MHD) found in our population was 78.5%, which is considered very high compared to rates found in other studies, rang- ing from 25%8 to 58%9. Many of these studies evaluated students from various fields of study, but even those that assessed the suspicion of MHD in dental students13,14 found lower rates than those found in our study. A high prevalence of MHD was observed in both the pre-clinical stage (73.2%) and the clinical stage (82.2%), although this data did not show a statistically significant association with disorders. This may be due to the difficulties encountered throughout the dental education, from the admission and adaptation phase to the academic real- 14 Michigami et al. Braz J Oral Sci. 2025;24:e257207 ity, to some characteristics of the teaching-learning process throughout the course, which can affect the emotional well-being of students13. Although this data does not correlate with the suspicion of MHD, it is important to emphasize that these are high and thus concerning rates. One variable that showed a statistically significant correlation (p<0.05) with the sus- picion of mental health disorders was being female (81.6%), which aligns with simi- lar studies conducted by Costa et al.14, as well as previous studies30-34 that reported similar results in female samples within the context of primary healthcare in Brazil. This finding is consistent with the literature, which states that women have a higher prevalence of mental health disorders, and temporomandibular disorders are the third most common health problem among women in developed countries and the fifth in non-developed countries14,34,35. Thus, health courses present certain peculiarities in the educational process that negatively impact the physical and psychological health of students. Stressors include concerns about exams and grades, fear of failure, lack of time to relax, excessive workload, fear of making mistakes, proximity to pathological processes, and difficulty in learning clinical procedures14,35-38. Additionally, constant exposure to an inhospitable environment surrounded by disease processes and human suffer- ing may predispose students to a higher risk of developing minor mental disorders as well as Burnout Syndrome39,40. Socio-demographic variables did not demonstrate correlation with MHD, supporting the results of other studies8,13, and differing from a study40 that reported age range as a significantly associated factor with MHD. Nonetheless, Dentistry presents peculiarities in its profession, such as patient contact, financial factors, specific working postures, and working within the con- fined space of the oral cavity, which categorizes its professionals as a highly stressed group39. Literature indicates that the chronicity of this stress, along with factors such as lack of energy, feelings of exhaustion, job dissatisfaction, and emotional instability, can lead to the development of Burnout Syndrome. Moreover, it is possible for this syndrome to develop early, starting during the learning period of the profession40. It can be concluded that the dental environment experienced by the participating stu- dents in this study presents stressors that contribute to high levels of stress among students. The main identified stressors were grades and evaluation methods, fear of failure, lack of time for relaxation and leisure, and they prevail among female students in the clinical stage. The high prevalence of suspected minor mental disorders in the female gender and in both the pre-clinical and clinical stages suggests that students are experiencing psychological distress. Data availability The entire dataset supporting the results of this study is available upon request from the corresponding author. 15 Michigami et al. Braz J Oral Sci. 2025;24:e257207 Conflict of interest No potential conflict of interest relevant to this article was reported. Author Contributions Julia Tiemy Michigami and Isabela Antunes de Medeiros: contributed to the development and writing of the project, execution of data collection, data tabulation, data analysis, and the writing and correction of the article. Luis Eduardo Genaro: contributed to the development of the project and the correction of the article. Elaine Pereira da Silva Tagliaferro: contributed to the development of the project and the correction of the article. Silvio Rocha Corrêa da Silva: execution of data collection and data analysis. Aylton Valsecki Júnior: contributed to the development of the project and the correction of the article. Fernanda Lopez Rosell: contributed to the development and writing of the project, supervision, data tabulation, data analysis, and the correction of the article. All authors actively revised and approved the final version of the manuscript. References 1. Margis R, Picon P, Cosner AF, Silveira RO. [Stressfull life-events, stress and anxiety]. Rev Psiquiatr Rio Gd Sul. 2003 Apr;25(suppl 1):65-74. Portuguese. doi: 10.1590/S0101-81082003000400008. 2. Rovida TAS, Sumida DH, Santos AS, Moimaz SAS, Garbin CAS. [Stress and lifestyle of freshmen in dentistry course]. Rev ABENO. 2015;15(3):26-34. Portuguese. doi: 10.30979/rev.abeno.v15i3.193. 3. Pani SC, Al Askar AM, Al Mohrij SI, Al Ohali TA. Evaluation of stress in final-year Saudi dental students using salivary cortisol as a biomarker. J Dent Educ. 2011 Mar;75(3):377-84. doi: 10.1002/j.0022-0337.2011.75.3.tb05051.x. 4. Manolova MS, Stefanova VP, Panayotov IV, Romieu G, Belcheva AB, Markova KB, et al. Perceived sources of stress in fifth year dental students--a comparative study. Folia Med (Plovdiv). 2012 Apr-Jun;54(2):52-9. doi: 10.2478/v10153-011-0089-3. 5. Rocha ES, Sassi AP. [Minor mental disorders among medical students]. Rev Bras Educ Med. 2013;37(2):210-6. Portuguese. 6. Fiorotti KP, Rossoni RR, Borges LH, Miranda AE. [Common mental disorders in medical students: prevalence and associated factors]. J Bras Psiquiatr. 2010;59(1):17-23. Portuguese. doi: 10.1590/S0047-20852010000100003. 7. Adewuya AO, Ola BA, Aloba OO, Mapayi BM, Oginni OO. Depression amongst Nigerian university students. Prevalence and sociodemographic correlates. Soc Psychiatry Psychiatr Epidemiol. 2006 Aug;41(8):674-8. doi: 10.1007/s00127-006-0068-9. 8. Cerchiari EAN, Caetano D, Faccenda O. [Prevalence of minor mental disorders in undergraduate students]. Est Psicol (Natal). 2005;10(3):413-20. Portuguese. doi: 10.1590/S1413-294X2005000300010. 9. Neves MCC, Dalgalarrondo P. [Self-referred mental disorders in university students]. J Bras Psiquiatr. 2007;56(4):237-44. Portuguese. doi: 10.1590/S0047-20852007000400001. 10. Castro VR. [Reflections on the mental health of university student: empirical study with students of a public institution of higher education]. Rev Gest Foco. 2017;9(1):380-401. 16 Michigami et al. Braz J Oral Sci. 2025;24:e257207 11. Fonseca J, Divaris K, Villalba S, Pizarro S, Fernandez M, Codjambassis A, et al. Perceived sources of stress amongst Chilean and Argentinean dental students. Eur J Dent Educ. 2013 Feb;17(1):30-8. doi: 10.1111/eje.12004. Epub 2012 Oct 1. 12. Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, Bedos C. A systematic review of stress in dental students. J Dent Educ. 2014 Feb;78(2):226-42. doi: 10.1002/j.0022-0337.2014.78.2.tb05673.x. 13. Facundes VLD, Ludermir AB. Common mental disorders among health care students. Rev Bras Psiquiatr. 2005;27(3):194-200. doi: 10.1590/S1516-44462005000300007. 14. Costa EFO, Rocha MMV, Santos ATRA, Melo EV, Martins LAN, Andrade TM. Common mental disorders and associated factors among final-year healthcare students. Rev Assoc Med Bras. 2014;60(6):525-30. doi: 10.1590/1806-9282.60.06.009. 15. Sangiorgio JPM, Araujo PM, Navarro CH, Zen IR, da Costa SC, Ribeiro PHV, Dezan-Garbelini CC. Dental environment stress: Findings among Lusophone dental students. Bras Res Pediat Dent Integr Clin. 2016;16(1):411-24. doi: /10.4034/PBOCI.2016.161.43. 16. Busnello, E, Lima B, Bertolote JM. [Intercultural aspects of classification and diagnosis psychiatric and psychosocial topics in Vila Sao Jose do Murialdo]. J Bras Psiquiatr. 1983;32(4):207-10. Portuguese. 17. Kumar S, Dagli RJ, Mathur A, Jain M, Prabu D, Kulkarni S. Perceived sources of stress amongst Indian dental students. Eur J Dent Educ. 2009 Feb;13(1):39-45. doi: 10.1111/j.1600-0579.2008.00535.x. 18. Uraz A, Tocak YS, Yozgatligil C, Cetiner S, Bal B. Psychological well-being, health, and stress sources in Turkish dental students. J Dent Educ. 2013 Oct;77(10):1345-55. doi: 10.1002/j.0022-0337.2013.77.10.tb05609.x 19. Agius AM, Gatt G, Vento Zahra E, Busuttil A, Gainza-Cirauqui ML, Cortes ARG, et al. Self-reported dental student stressors and experiences during the COVID-19 pandemic. J Dent Educ. 2021 Feb;85(2):208-15. doi: 10.1002/jdd.12409. Epub 2020 Sep 14. 20. Abu-Ghazaleh SB, Sonbol HN, Rajab LD. A longitudinal study of psychological stress among undergraduate dental students at the University of Jordan. BMC Med Educ. 2016 Mar;16:90. doi: 10.1186/s12909-016-0612-6. 21. Acharya S. Factors affecting stress among Indian dental students. J Dent Educ. 2003 Oct;67(10):1140-8. doi: 10.1002/j.0022-0337.2003.67.10.tb03707.x. 22. Morse Z, Dravo U. Stress levels of dental students at the Fiji School of Medicine. Eur J Dent Educ. 2007 May;11(2):99-103. doi: 10.1111/j.1600-0579.2007.00435.x. 23. Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and psychological disturbance among dental students in the West Indies. J Dent Educ. 2002 Sep;66(9):1021-30. doi: 10.1002/j.0022-0337.2002.66.9.tb03569.x. 24. Rajab LD. Perceived sources of stress among dental students at the University of Jordan. J Dent Educ. 2001 Mar;65(3):232-41. doi: 10.1002/j.0022-0337.2001.65.3.tb03392.x. 25. Polychronopoulou A, Divaris K. Perceived sources of stress among Greek dental students. J Dent Educ. 2005 Jun;69(6):687-92. doi: 10.1002/j.0022-0337.2005.69.6.tb03952.x. 26. Al-Sowygh ZH. Academic distress, perceived stress and coping strategies among dental students in Saudi Arabia. Saudi Dent J. 2013 Jul;25(3):97-105. doi: 10.1016/j.sdentj.2013.05.002. 27. Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update. 1999 Apr;26(3):94-8, 100. doi: 10.12968/denu.1999.26.3.94. 28. Westerman GH, Grandy TG, Ocanto RA, Erskine CG. Perceived sources of stress in the dental school environment. J Dent Educ. 1993 Mar;57(3):225-31. 17 Michigami et al. Braz J Oral Sci. 2025;24:e257207 29. Maragno L, Goldbaum M, Gianini RJ, Novaes HM, César CL. [Prevalence of common mental disorders in a population covered by the Family Health Program (QUALIS) in São Paulo, Brazil]. Cad Saude Publica. 2006 Aug;22(8):1639-48. Portuguese. doi: 10.1590/s0102-311x2006000800012. 30. Lima MC, Menezes PR, Carandina L, Cesar CL, Barros MB, Goldbaum M. [Common mental disorders and the use of psychoactive drugs: the impact of socioeconomic conditions]. Rev Saude Publica. 2008 Aug;42(4):717-23. Portuguese. doi: 10.1590/s0034-89102008005000034. 31. Fortes S, Lopes CS, Villano LA, Campos MR, Gonçalves DA, Mari Jde J. Common mental disorders in Petrópolis-RJ: a challenge to integrate mental health into primary care strategies. Braz J Psychiatry. 2011 Jun;33(2):150-6. doi: 10.1590/s1516-44462011000200010. 32. Borges TL, Hegadoren KM, Miasso AI. [Common mental disorders and use of psychotropic medications in women consulting at primary care units in a Brazilian urban area]. Rev Panam Salud Publica. 2015 Sep;38(3):195-201. Portuguese. 33. Rodrigues-Neto JF, Figueiredo MFS, De Faria AAS, Fagundes M. [Commom mental disorders and the use of complementary and alternative medicine population based survey] J Bras Psiquiatr. 2008;57(4):233-9. Portuguese. doi: 10.1590/S0047-20852008000400002. 34. Wexler M. Mental health and dental education. J Dent Educ. 1978 Feb;42(2):74-7. 35. Omigbodun OO, Odukogbe AT, Omigbodun AO, Yusuf OB, Bella TT, Olayemi O. Stressors and psychological symptoms in students of medicine and allied health professions in Nigeria. Soc Psychiatry Psychiatr Epidemiol. 2006 May;41(5):415-21. doi: 10.1007/s00127-006-0037-3. 36. Millan LR, Arruda PC. [Psychological assistance to medical students: 21 years of experience]. Rev Assoc Med Bras. 2008;54(1):90-4. Portuguese. doi: 10.1590/S0104-42302008000100027. 37. Finger G, Silva ER, Falavigna A. Use of methylphenidate among medical students: a systematic review. Rev Assoc Med Bras. 2013;59(3): 285-9. doi: 10.1016/j.ramb.2012.10.007. 38. Lloyd C, Musser LA. Psychiatric symptoms in dental students. J Nerv Ment Dis. 1989 Feb;177(2):61-9. doi: 10.1097/00005053-198902000-00001. 39. Gorter R, Freeman R, Hammen S, Murtomaa H, Blinkhorn A, Humphris G. Psychological stress and health in undergraduate dental students: fifth year outcomes compared with first year baseline results from five European dental schools. Eur J Dent Educ. 2008 May;12(2):61-8. doi: 10.1111/j.1600-0579.2008.00468.x. 40. Costa EF, Andrade TM, Silvany Neto AM, Melo EV, Rosa AC, Alencar MA, et al. Common mental disorders among medical students at Universidade Federal de Sergipe: a cross-sectional study. Rev Bras Psiquiatr. 2010;32(1):11-9. doi: 10.1590/S1516-44462010000100005.