Perceived stress, dental environmental stress, and academic performance among dental students: a cross-sectional study

Introduction

Dental education is generally recognized as one of the most academically and psychologically demanding professional training environments. Dental students are frequently exposed to substantial stressors related to intensive didactic coursework, preclinical skill acquisition, patient care responsibilities, performance expectations, and highly competitive academic settings. These stressors may adversely affect students’ psychological wellbeing, academic performance, and professional development (Alzahem et al., 2011; Sanders and Lushington, 2002). Previous literature has consistently demonstrated elevated levels of stress, anxiety, burnout, and emotional exhaustion among dental students compared with the general population and students in other health-related disciplines (Gorter et al., 2008; Jiménez-Ortiz et al., 2019; Lugassy et al., 2025; Smolana et al., 2022).

Stress experienced during dental education may originate from both general life stressors and stressors specific to the dental training environment. The Perceived Stress Scale (PSS) is among the most commonly used instruments for assessing perceived psychological stress, whereas the Dental Environment Stress (DES) questionnaire evaluates stressors unique to dental education, including workload, examinations, patient management, faculty interactions, and manual skill requirements (Lee, 2012; Sfeatcu et al., 2021). Studies using these instruments have reported that academic workload, fear of academic failure, and clinical responsibilities are among the most prominent contributors to stress in dental students (Alzahem et al., 2011; Sanders and Lushington, 2002). Furthermore, elevated stress levels have been associated with impaired concentration, reduced academic satisfaction, and burnout symptoms (Collin et al., 2020; Pereira et al., 2022).

Although the relationship between stress and academic performance has been investigated previously, findings remain inconsistent. Some studies have demonstrated significant negative associations between psychological stress and academic achievement, whereas others have reported weak or non-significant relationships (Atif et al., 2025; Ersan et al., 2018; Gorter et al., 2008; Lugassy et al., 2025). These inconsistencies may also reflect the broader psychological mechanisms through which students’ emotional functioning, self-efficacy, and test-related anxiety may influence academic performance. Recent evidence in higher education further indicates that psychological factors related to emotional functioning and cognitive test anxiety may be meaningfully associated with students’ academic performance, supporting the examination of psychological mechanisms alongside contextual academic stressors (Vasiou et al., 2025). Thus, the relationship between stress and academic achievement may not be linear or uniform across students, as academic outcomes eventually reflect the interplay of psychological, behavioral, and educational factors.

In addition, relatively limited evidence exists regarding the potential role of structured wellness interventions in mitigating stress and supporting academic performance among dental students. Recent evidence synthesizing stress-management approaches in dental education indicates considerable heterogeneity in the content, implementation, and evaluation of such strategies, reinforcing the need for further systematic investigation of structured wellness initiatives (Boehm et al., 2026). To address student wellbeing, the UCLA School of Dentistry implemented the Integrative Mind-Body Wellness Initiative (IMBWI), a wellness-focused program designed to promote resilience, mindfulness, self-awareness, and healthy coping strategies, as well as professional support if needed, among dental students. Accordingly, this study addressed four research questions: (1) What are the levels of perceived stress and dental environmental stress among dental students? (2) Are perceived stress and dental environmental stress associated with academic performance? (3) Which demographic, academic, and behavioral characteristics are associated with perceived and dental environmental stress? and (4) Is participation in the IMBWI associated with stress levels and academic performance? These questions guided the subsequent analyses of stress levels, academic outcomes, and factors associated with stress and academic performance among dental students at the UCLA School of Dentistry.

Materials and methods

Study design and participants

This cross-sectional study was conducted among dental students enrolled at the UCLA School of Dentistry. All currently enrolled dental students in the Doctor of Dental Surgery (DDS) program, including first- through fourth-year students (D1–D4) and students enrolled in the Advanced Standing International Program, were eligible to participate. Students on academic leave or those with incomplete survey responses were excluded from the study. Participation was voluntary, and electronic informed consent was obtained from all participants prior to survey completion. Data was collected using an anonymous online questionnaire distributed to dental students. The survey included demographic and academic variables, measures of perceived stress and dental environmental stress, indicators of academic performance, and questions regarding participation in the IMBWI.

Ethical considerations

The study was determined to be exempt from review by the University of California Los Angeles Office of the Human Research Protection Program (IRB#25-2557).

Measures

Demographic variables included gender and current year of study. Academic-related variables included self-rated academic performance, overall academic performance classification, academic standing relative to peers, prior academic challenges, weekly study hours outside scheduled classes and clinics, and weekly time dedicated to self-care activities. Academic challenges or struggle was defined as reporting at least one of the following experiences: repeating a course, receiving a “No Pass” grade, being placed on academic probation, or requiring academic or clinical remediation. Participation in the IMBWI was dichotomized into participation (“once,” “sometimes,” or “always”) versus no participation.

Procedure and data collection

General perceived stress was assessed using the 10-item Perceived Stress Scale (PSS-10), a validated instrument designed to measure the extent to which individuals perceive situations in their lives as stressful. Responses were recorded using a five-point Likert scale ranging from “Never” (0) to “Very often” (4). Total PSS scores ranged from 0 to 40, with higher scores indicating greater perceived stress. Stress levels were categorized according to established cutoffs as low (0–13), moderate (14–26), and high (27–40) based on established cutoffs (Lee, 2012).

Dental school-specific stressors were assessed using the Dental Environment Stress (DES) questionnaire (Garbee et al., 1980). The instrument evaluates stress related to academic workload, patient care, manual skills, faculty and administration, personal problems, family responsibilities, and financial obligations. Responses were recorded on a five-point Likert scale ranging from “Not stressful” (1) to “Extremely stressful” (5). Total DES scores ranged from 25 to 125, with higher scores indicating greater environmental stress (Sfeatcu et al., 2021).

Academic self-efficacy was assessed using three items developed specifically for the present study to capture students’ perceived ability to meet key academic demands: (1) keep up with didactic coursework, (2) perform well on written examinations, and (3) perform well on preclinical and clinical assessments. Each item was rated on a five-point Likert scale ranging from “Completely disagree” (1) to “Completely agree” (5).

Survey responses were collected from March to May 2026. A total of 407 students were eligible to participate (D1: 88; D2: 88; D3: 113; D4: 118), of whom 135 completed the survey, yielding a response rate of 33.2%. Three reminder emails were distributed at approximately 2 weeks intervals to all students enrolled in the DDS program.

Outcome variables

The primary outcome variables were perceived stress (PSS score and binary PSS category), dental environmental stress (DES score and binary DES category), and overall academic performance.

Statistical analysis

Data analysis was performed using Microsoft Excel and R Statistical Software (version 4.2.2; R Core Team, 2022). Continuous variables were assessed for normality using Q-Q plots and the Shapiro–Wilk test and are presented as means and standard deviations, whereas categorical variables are presented as frequencies and percentages. PSS-10 responses were scored on a five-point Likert scale ranging from 0 (“Never”) to 4 (“Very often”), with positively worded items reverse-coded prior to analysis. Total scores ranged from 0 to 40. DES questionnaire items were scored from 1 (“Not stressful”) to 5 (“Extremely stressful”), with total scores ranging from 25 to 125.

For logistic regression analyses, PSS and DES scores were dichotomized using sample mean values into low (≤ mean) and high (> mean) stress groups. Academic performance was categorized as high versus low performance. Participants reporting either “several Honors, otherwise Passes” or “some Honors and mostly Passes” were classified as high academic performers, whereas all remaining categories were classified as low academic performers.

Spearman's correlation analysis was used to assess associations between stress scores and academic performance ranking. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with perceived stress, dental environmental stress, and academic performance. Analyses addressing the primary study objectives were considered primary analyses, whereas additional analyses examining other potential associations were considered exploratory. Results were reported as odds ratios (ORs), regression estimates, 95% confidence intervals (CIs), and p-values. Given the number of statistical comparisons, p-values were interpreted cautiously because no formal adjustment for multiple testing was performed. Greater emphasis was placed on the magnitude and precision of effect estimates and their 95% CIs rather than statistical significance alone. Statistical significance was set at p < 0.05.

Results

Participant demographic characteristics

The demographic and academic characteristics of the participants are presented in Table 1. After excluding participants with incomplete or missing data required for the primary analyses, the final analytic sample consisted of 74 students, of whom 53 (71.62%) were female. The largest proportion of participants were enrolled in the third dental year (D3) (39.19%), followed by first-year students (20.27%). Overall, 48 students (64.86%) reported participating in the IMBWI at least once.

Table 1. Demographic and academic characteristics of the study participants.

Regarding academic performance, 41 students (55.41%) ranked within the middle 50% of their class, while 22 (29.73%) ranked within the top 25%. In terms of overall academic outcomes, 37 participants (50%) reported achieving “some Honors and mostly Passes,” whereas 17 (22.97%) reported “several Honors, otherwise Passes.” Academic challenges were relatively common, with 25 students (33.78%) reporting a prior “No Pass” grade and 26 (35.14%) requiring academic or clinical remediation at some point during dental school.

Participants reported moderate-to-high levels of academic self-efficacy. The mean (SD) scores for confidence in keeping up with didactic coursework, performing well in written examinations, and performing well in preclinical and clinical assessments were 3.54 (1.05), 3.69 (0.87), and 3.53 (0.94), respectively. With respect to lifestyle habits, 36 students (48.65%) reported spending fewer than 10 h weekly on self-care activities, whereas 31 (41.89%) reported spending 10–19 h weekly on self-care.

Perceived stress and dental environmental stress

The stress-related outcomes are summarized in Table 2. The mean (SD) PSS score was 21.64 (6.74). Based on established PSS categories, 48 students (64.86%) demonstrated moderate stress levels, while 18 (24.32%) demonstrated high stress levels. For regression analyses, participants were dichotomized according to the mean PSS score, with 35 students (47.30%) categorized as having high perceived stress. The mean (SD) DES score was 58.03 (15.53), with 29 participants (39.19%) categorized as having high environmental stress. Among the DES domains, the highest mean scores were observed for personal problems (12.97 ± 3.71) and academic-related stressors (10.58 ± 4.29).

Table 2. Perceived stress and dental environmental stress measures among the participants.

PSS, perceived stress scale; DES, dental environmental stress.

Multivariable logistic regression analysis identified no statistically significant associations between perceived stress and gender, academic phase, academic struggle, or academic self-efficacy (Table 3). However, participation in the IMBWI was associated with lower odds of high perceived stress (OR = 0.35, 95% CI: 0.11–1.03, p = 0.063). Similarly, spending ≥10 h weekly on self-care activities was associated with lower odds of high perceived stress, with the estimated association not reaching the conventional statistical significance threshold (OR = 0.35, 95% CI: 0.11–1.06, p = 0.071).

Table 3. Logistic regression analysis of factors associated with high perceived stress.

In multivariable logistic regression analyses, neither gender nor academic struggle demonstrated significant associations with high DES scores (Table 4). However, students who reported studying ≥10 h weekly outside scheduled classes and clinics had lower estimated odds of high environmental stress (OR = 0.20, 95% CI: 0.05–0.67, p = 0.013). Similarly, spending ≥10 h weekly on self-care activities was associated with lower estimated odds of high DES scores (OR = 0.19, 95% CI: 0.05–0.62, p = 0.009).

Table 4. Logistic regression analysis of factors associated with high dental environmental stress.

Factors associated with academic performance

The multivariable logistic regression model evaluating factors associated with overall academic performance is presented in Table 5. Neither gender nor current academic phase demonstrated statistically significant associations with academic performance. However, participation in the IMBWI was associated with lower odds of belonging to the high academic performance group (OR = 0.09, 95% CI: 0.01–0.55, p = 0.016). In addition, students with a history of academic struggle had substantially lower estimated odds of high academic performance (OR = 0.01, 95% CI: 0.00–0.08, p < 0.001).

Table 5. Logistic regression analysis of factors associated with academic performance.

No statistically significant associations were identified between academic performance and either perceived stress categories (OR = 0.15, 95% CI: 0.01–1.35, p = 0.107) or environmental stress categories (OR = 1.07, 95% CI: 0.11–10.25, p = 0.954). DES domain scores did not differ between students with high and low academic performance (Figure 1).

Spearman's correlation analysis demonstrated a moderate positive correlation between PSS and DES scores (ρ = 0.65, p = 0.001). In contrast, perceived academic performance ranking showed weak negative, non-significant correlations with both PSS scores (ρ = −0.20, p = 0.08) and DES scores (ρ = −0.09, p = 0.43) (Figure 2).

Discussion

The present study evaluated perceived stress, dental environmental stress, and academic performance among dental students and explored factors associated with stress outcomes and academic achievement, including participation in the UCLA School of Dentistry IMBWI. Overall, participants demonstrated moderate levels of perceived stress and dental environmental stress. Across many countries and schools, dental education was consistently described as a highly stressful training path that can impact students’ mental health and performance (Collin et al., 2020; Elani et al., 2014; Gorter et al., 2008; Lee, 2012; Lugassy et al., 2025; Menacho-Rivera et al., 2025; Mishra et al., 2025, Sfeatcu et al., 2021).

The mean PSS score reported in this study indicated that most students experienced moderate perceived stress, while approximately one-quarter demonstrated high stress levels based on established PSS categories. Similarly, the DES findings revealed considerable stress related to academic workload, faculty and administrative interactions, patient care responsibilities, and personal concerns. Among the DES domains, personal problems and academic-related stressors demonstrated the highest scores. These findings are consistent with prior studies identifying examinations, workload, and clinical responsibilities as major contributors to psychological distress among dental students (Guthardt et al., 2024; Stormon et al., 2022).

Perceived stress and dental environmental stress demonstrated a moderate positive correlation, suggesting that students experiencing higher general psychological stress also tended to report greater stress associated with the dental educational environment. This finding supports the conceptual overlap between general psychological distress and institution-specific academic stressors, consistent with previous studies demonstrating interconnected dimensions of stress, burnout, and academic wellbeing among health professions students (Franzen et al., 2021; Mladen et al., 2019).

Despite the relatively high stress levels observed, neither perceived stress nor dental environmental stress was associated with academic performance in the multivariable analyses. Similarly, correlation analyses demonstrated weak negative but non-significant associations between stress scores and academic ranking. Although prior literature has frequently suggested an inverse relationship between stress and academic achievement, the present findings indicate that stress measures were not strongly associated with the academic performance measures examined in this cohort. However, because of the cross-sectional design, the directionality and temporal relationship between stress and academic performance cannot be determined.

It is generally believed that academic performance in dental education is influenced by multiple interacting factors beyond psychological stress alone, including time management skills, resilience, learning strategies, level of institutional support, and underlying academic ability (Ali et al., 2024). It is also possible that students develop adaptive coping mechanisms that allow maintenance of academic performance despite elevated stress levels. Nevertheless, stress reduction programs and wellness initiatives remain important in dental education, as they enhance students’ overall wellbeing.

One notable finding was the association between academic challenges and lower academic performance. Students reporting prior academic setbacks, including course repetition, remediation, academic probation, or “No Pass” grades, demonstrated lower estimated odds of belonging to the high academic performance group. Academic struggle included prior “No Pass” grades and academic or clinical remediation, while the academic performance classification included categories containing “NP” or “NP/P.” Therefore, this overlap might have contributed to the large observed association and influenced other adjusted estimates in the multivariable model. Notably, students who spent more time engaged in self-care activities and studying outside scheduled academic hours demonstrated estimated lower odds of high dental environmental stress. These findings suggest that effective self-regulation and responsible study habits as well as engagement in self-care behaviors could correlate to improved stress management among dental students.

The IMBWI at the UCLA School of Dentistry was implemented in 2024. The initiative comprises voluntary wellness activities and a mandatory wellness course integrated into the D1–D4 curriculum. Voluntary activities include access to a UCLA Counseling and Psychological Services (CAPS) satellite office, weekly yoga and meditation, and periodic wellness activities and workshops addressing stress management, burnout prevention, self-care, and leadership. The mandatory course incorporates mind-body wellness practices and educational content through lectures and small-group seminars focused on stress reduction, burnout prevention, self-care, test-taking anxiety, conflict resolution, and leadership.

Participation in the IMBWI demonstrated a trend toward lower perceived stress and lower environmental stress, although these associations did not necessarily reach statistical significance. Participation in the IMBWI was associated with lower odds of high academic performance. This finding should be interpreted cautiously and does not imply a detrimental effect of the wellness initiative itself. Rather, it is possible that students experiencing greater stress, academic concerns, or psychological burden may have been more likely to seek participation in wellness-related activities, resulting in reverse causality or self-selection bias. Similar patterns have been reported in observational studies evaluating voluntary wellness interventions, where students with greater perceived stress, anxiety, or perceived need for stress-management support were often more likely to participate (Kotter et al., 2016; Stone et al., 2024). A sensitivity analysis excluding the academic-struggle variable from the multivariable model resulted in attenuation of the estimated association between IMBWI participation and high academic performance. Although the direction of the association remained unchanged, the wider confidence interval and loss of statistical evidence indicate sensitivity to model specification.

Limitations of the current study include the cross-sectional design, relatively small sample size, single-institution setting, and potential nonresponse and selection bias, which may limit generalizability. The study relied on self-reported measures, including academic performance, which may have introduced reporting bias. IMBWI participation was voluntary and self-selected, potentially introducing selection bias in comparisons between participants and non-participants. The use of sample-dependent mean-based categorization of PSS and DES scores for logistic regression analyses may have resulted in loss of information and reduced statistical power. The absence of sample-specific reliability estimates is an additional limitation. Despite these limitations, the study provides insight into the psychological wellbeing and academic experiences of dental students within a contemporary dental education environment. Future longitudinal studies involving larger, multi-institutional samples and objective measures of academic performance are needed to further clarify these relationships.

Conclusion

Dental students reported moderate levels of perceived and dental environment–related stress, with academic and personal factors representing prominent domains of reported dental environment–related stress. Although higher stress scores were associated with lower academic performance, these relationships were not statistically significant. Students with a history of academic challenges demonstrated significantly lower academic performance, whereas greater engagement in self-care activities and independent study time was associated with lower environmental stress. Participation in the Integrative Mind-Body Wellness Initiative (IMBWI) was associated with lower stress scores, although these associations did not reach statistical significance. Collectively, these findings suggest the potential value of institutional strategies that support student well-being and foster supportive learning environments in dental education. Further research with larger samples is warranted to evaluate the impact of wellness initiatives on stress reduction and academic outcomes among dental students.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2026.1948012/full#supplementary-material

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Footnotes

Edited by: Moises Betancort, University of La Laguna, Spain

Reviewed by: Konstantinos Mastrothanasis, Open University of Cyprus, Cyprus

Katayoun Katebi, Tabriz University of Medical Sciences, Iran