The implications of oral health education interventions in providing oral hygiene care for individuals with visual impairment: A systematic review.

INTRODUCTION: Individuals with visual impairment (VI) are doubly disadvantaged by their lack of vision and poor oral hygiene (OH). Implementing oral health education (OHE) interventions should be set as goals to improve OH status and prevent oral diseases. However, few studies have examined the specific teaching method of OH skills. This study aimed to identify the most influential OHE interventions enabling individuals with VI worldwide, especially those in countries where VI is most frequent, to maintain OH and improve knowledge and practices. METHODS: An extensive literature review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis method. This study systematically searched electronic databases (PubMed via Medline, Cochrane, Embase, and Google Scholar) using expert-validated keywords, complemented by manual searches, to identify relevant articles published between April 1, 2012, and September 30, 2022. RESULT: PICOS criteria were formulated for study inclusion. The bibliographical search identified 1485 articles, which were subsequently filtered. Two researchers separately screened the articles for eligibility and to reduce the risk of bias in the included studies. Finally, the most pertinent 21 articles were scrutinized for data synthesis. CONCLUSION: Most studies identified combination methods, including customized educational demonstrations, as the best at improving OH status, knowledge, and practices. However, long-term, rigorously designed, and effective patient-centered communication trials, including those on innovative methods, are still needed for individuals with VI.

Bruxism management in individuals with autism spectrum disorder and down syndrome - A systematic review.

BACKGROUND: In dentistry, association between bruxism and individuals with autism spectrum disorders (ASD) and Down Syndrome (DS) is high. Bruxism is one of the most common oral and psychophysiological disorders, that is still an unsolved issue with limited data. OBJECTIVES: The purpose of this systematic review (SR) was to evaluate evidence about bruxism and its management in individuals with ASD and DS. MATERIALS AND METHODS: The researchers performed an electronic search using keywords on three databases, reference lists and complemented by manual searching from January 2000 to February 2023 to find out the relevant documents. An extensive literature review using the "Preferred Reporting Items for Systematic Review and Meta Analysis" method was carried out. PICO parameters were formulated, and studies risk of bias was evaluated using the JBI critical appraisal checklist tool for case reports. RESULTS: Out of 527 documents, 8 case studies and one review paper were identified as final articles for data synthesis. The findings showed, bruxism was reduced for all the participants with ASD and DS after implementation of functional analysis or dental treatment. CONCLUSION: The current SR found that despite the positive results of all the studies, there was a lack of evidence due to a limited number of studies and only case studies were conducted through functional analysis and dental treatment. NOVELTY: This SR is the first study on bruxism treatments in individuals with ASD and DS that included all the available studies (n = 9) since last 23 years and the first study that specifically addresses the incorporation of case reports in a systemic review.

Analysis of Oral Health Literacy in Caregivers of Special Needs Individuals in Special Schools and Social Institutions in Jakarta.

BACKGROUND: Individuals with special needs (IWSN) are susceptible to oral conditions such as caries and periodontal disease. In order to improve oral health of IWSN, it is important to improve the oral health literacy (OHL) of caregivers, as they play an important role in the daily hygiene and personal care of these people. OBJECTIVE: This study aimed to analyze the OHL in caregivers of IWSN in special schools (informal caregivers) and social institutions for people with disabilities (professional caregivers) in Jakarta, Indonesia. METHODS: The study was conducted with a cross-sectional and descriptive analytic design with a cluster sampling method of 400 informal and professional caregivers. The study utilized the validated Health Literacy Dentistry-Indonesian Version (HeLD-ID) questionnaire to measure OHL. Quantitative data was analyzed using non-parametric Kruskal Wallis and Mann Whitney tests (significant level p < 0.05). RESULTS: The median total OHL score of respondents was 3.14 (0.24-4) for informal caregivers and 3.21 (0-4) for professional caregivers. The OHL score of the two populations showed significant differences in the domains of receptivity (p = 0.036), understanding (p = 0.030), and economic barriers (p = 0.022). Significant differences in OHL scores were also noted among caregivers according to their sociodemographic characteristics, such as level of education, and number of IWSN handled. CONCLUSION: Informal and professional caregivers in this study showed good level of OHL. To elucidate the relationship between caregiver's level of OHL with IWSN, further study is necessary.

Analysis of Health Profile and Treatment Needs of Patients with Special Health Care Needs at a Malaysian Teaching Hospital: A 6-Year Observation.

Aims and Objectives: Special care dentistry (SCD) provides oral health care to disabled individuals in an environmental, cultural or social setting that supports their oral health. This study aimed to analyze the profiles of patients managed at an SCD clinic in a teaching hospital based on their sociodemographic background, medical condition or disability, dental diagnosis and treatment provided. Materials and Methods: This retrospective audit study included patients seen from the clinic's inception in January 2017 until June 2022, retrieved from the faculty's record management system. The pattern of patients seen was arranged on an Excel sheet and analyzed using SPSS. Quantitative data were analyzed via descriptive analysis (frequency) and chi-square test (P < 0.05). Results: A 220% surge in the number of patients treated between January 2017 and June 2022, from two to 91 years old, with more male patients seen. Most patients had an intellectual disability (49.7%), followed by medical compromised (16.4%) and genetic conditions or syndromes (12.0%). 43% of had caries, which is more prevalent in women, and 31.6% had periodontal disease, with the majority being between the ages of 21 and 40. Periodontal treatment accounted for most of the dental treatment (76.1%). Even though only a small percentage of endodontic therapy was performed (2.4%), a significant association was found between the treatment, gender and age group of patients seen in the clinic. Conclusion: Considering their health profile, oral diagnosis and therapy, this study demonstrated the varied sorts of patients encountered in an SCD specialist clinic. This useful information will be beneficial in the development of a comprehensive care dentistry center for this community.

Special care dentistry education during the COVID-19 pandemic: The impact of online peer-assisted learning.

OBJECTIVES: This study aims to analyze the impact and students' perceptions of online peer-assisted learning (OPL), developed as an alternative and innovative approach to Special Care Dentistry (SCD) training during the COVID-19 pandemic. Online peer-assisted learning (OPL) is an alternative pedagogical approach that combines online education and peer-assisted teaching. METHODS: The OPL session was conducted by two postgraduate students in SCD (as teachers), to final year undergraduate dental students (as learners) (n = 90), supervised by two specialists in SCD-related areas (as supervisors). Vetted online pre- and post-intervention quizzes were conducted before and after the session, respectively, followed by an online validated feedback survey of the students' learning experiences. Meanwhile, a reflective session was conducted between the postgraduate students and supervisors to explore their perceptions of OPL. Quantitative data was analyzed via paired t-test (significance level, P < .05). Qualitative data was analyzed via thematic analysis. RESULTS: Overall, 68 (response rate = 75.6%) and 81 (response rate = 90.0%) undergraduate students completed the quiz and feedback survey, respectively. There was a significant difference in total mean scores, and mean scores of 7 (out of 10) individual items on the quizzes. Most students offered positive reviews of multiple aspects of OPL. They acknowledged the benefit of OPL for its content and preparation process, technology utilized, and experts' roles. Postgraduate students perceived that OPL encourages knowledge-recall and utilization of technology-based educational tools, while improving their teaching skills. CONCLUSION: Students provided positive responses toward the implementation of OPL as an innovative approach to the teaching and learning of SCD during the COVID-19 pandemic.

Correlates of dental visits in children with hearing loss: An application of the theory of planned behaviour.

BACKGROUND: Maintenance of oral health of children with special needs requires the involvement of caregivers who are also responsible for ensuring adherence to professional recommendations, including dental visits. AIM: This study aimed at exploring the correlates of dental visits of children with hearing loss (CWHL) in Indonesia using the theory of planned behaviour (TPB). DESIGN: This cross-sectional study involved purposive sampling methods, conducted via an online survey administered to mothers of CWHL who were aged 5-12 years. Constructs of the TPB model were collected, including the mother's attitudes, subjective norms, perceived behaviour control (PBC) and intention towards dental visits for CWHL. Dental visits were measured by asking whether their children had a dental visit within the last 12 months. Data were analysed using SPSS for descriptive and bivariate analyses. The significance level was set as p < .05. Partial least square structural equation modelling (PLS-SEM) was used to analyse measurement and structural TPB models. RESULTS: A total of 254 mothers participated in this study. The final TPB model explained 35.4% and 9.2% of the variance in mothers' intention and behaviour towards their children's dental visits, respectively. Of all the included constructs from the TPB model, only PBC was significantly associated with intention and behaviour (p < .05). The mother's attitude and subjective norms did not significantly predict intention (p > .05). Intention did not significantly predict the mother's behaviour towards children's dental visits (p > .05). CONCLUSION: The TPB model revealed a construct associated with dental visit intention and behaviour in CWHL. This study suggested that effective promotion intervention should focus on the mother's PBC to increase parents' adherence to preventive dental visits in CWHL in Indonesia.

Exploring the Barriers and Expectations Towards Health Care Services Among Parents/Caretakers of People with Intellectual Disability in Kuantan, Malaysia: A Qualitative Study.

Backgrounds: People with intellectual disabilities (PWID) are often characterized by challenges in learning and difficulties in performing daily activities. These difficulties can have an impact not only on the individuals themselves but also on the people around them, especially their parents, caregivers, and healthcare workers. Therefore, establishing a positive relationship between parents or caregivers and individuals with disabilities is crucial as a key factor in promoting positive healthcare experiences and outcomes. Aim: This study aims to explore the barriers and perceptions toward healthcare services among parents or caretakers of people with intellectual disability, including the challenges and their expectations toward healthcare services. Materials and Methods: This was a qualitative study using purposive sampling. Thirty participants were contacted at the initial stage and invited to participate in the study. Semi-structured in-depth interviews were done among parents and caretakers of PWID who attended Special Care Dentistry and Paediatric Dentistry clinics in Sultan Ahmad Shah Medical Centre, Kuantan, Pahang. Topic guides were generated from literature review and expert opinions, followed by pilot interviews to refine them. However, after the interviews were done for the first 13 participants, we have reached data saturation, and no new themes emerged. The interviews were recorded, verbatim transcribed, and analyzed using Braun and Clarke's guidelines for thematic analysis. Results: The satisfaction of parents or caretakers toward healthcare services for PWID and positive experiences in receiving healthcare services were noted. However, the results revealed several barrier themes in seeking healthcare services: lack of availability of parking, longer waiting time, appointment time, crowded environment, limited information on the availability of the services, and longer travel duration. Furthermore, expectation themes emerged from this study: continuous follow-up, accessibility to healthcare services, and staff attitude.

Family Influences on the Dental Caries Status of Children with Special Health Care Needs: A Systematic Review.

Oral health is a likely source of health inequalities in children with special health care needs (CSHCN), according to multiple studies. This systematic review aimed to explore the evidence of family influence­as well as family features, such as societal variables and parents' perspectives­on these children's dental caries status. Embase, Ebsco, Scopus, PubMed, and Web of Science databases were all searched. All cross-sectional research published on the variables of family impact ranging from 2010 to 2021 were considered. The DMFT and dmft index was utilised for the report data of dental caries, whereas the National Heart, Lung, and Blood Institute (NHLBI) was used for the purposes of assessing quality. Of the 3861 records identified, 14 were eligible. Further, most of the studies had a caries prevalence of over 50%, (p-value < 0.005). Family influences imparted a significant relationship and association towards the dental caries status of the demographic being studied. The influences on the children included tooth brushing behaviour, parents' education level, parents' occupation level, diet pattern, dental visit, snacking frequency, parents' psychological status, family size, and parents' knowledge towards oral health. Future research should further explore the family functioning domains, specifically among the CSHCN population. This study was registered on PROSPERO, number CRD42021274923.

Factors affecting provision of oral health care for people with special health care needs: A systematic review.

Background: Special health care needs (SHCNs) individuals experience higher levels of dental problems including accessing oral health (OH) facilities. Improving standard of OH care in SHCNs requires identifying barriers and enablers. The aim of this study was to perform a systematic review of prior researches to identify OH care barriers and enablers for SHCN individuals. Methods: Electronic searching was conducted systematically in PubMed and Cochrane databases. The PICOS parameters were formulated for the inclusion of studies, and the PRISMA method was used to select the articles. Two reviewers independently screened the articles for eligibility and to minimise the risk of bias in the studies and also searched the contents of key articles, quality of methodology, outcomes and reference lists of all the studies included. Results: A total of 1316 (PubMed 956, Cochrane 360) studies were found initially and after title and abstract screening and also removal of duplication, reviewers selected 53 papers from PubMED and 19 articles from Cochrane to go through full articles and led to the final confirmation of 21 studies. Common challenges included lack of OH knowledge and awareness, difficulty in accessing treatment, transportation problem, treatment cost, and lack of inter-professional collaboration for specialized services. Potential solutions included OHE training and services for patients and caregivers, easy access to dental services, specialized dental practitioners and use of a combination of expertise to meet the demands of SHCN individuals. Conclusion: This brief analysis will establish dental obstacles to the provision of information to policymakers for SHCN population at organizational, individuals and policy levels. It will help in effective planning for providing and improving OH care quality in caregivers.

Perceptions of interprofessional education among Malaysian clinical healthcare students.

INTRODUCTION: Interprofessional education (IPE), which is aimed at improving the quality of patient care and overall health outcome, has been advocated to prepare future healthcare professionals for collaborative practice OBJECTIVES: This study aimed to investigate the perceptions of IPE among clinical healthcare students at a Malaysian institution METHODS: A validated questionnaire, developed from previous studies, was distributed online to selected final year students of 10 clinical programs from medical, dental, pharmacy and health sciences faculties (n = 501). Quantitative data was analyzed via chi-square test (significance value p < .05) using social sciences software (SPSS). RESULTS: The overall response rate was 76.4% (n = 383). About 63.2% of respondents reported having experienced IPE. This experience took place in lectures (32.1%) and online courses/webinars (36.2%). The majority of respondents provided positive feedback on various aspects of IPE. There was an insignificant difference among respondents across all programs in terms of their perception of its importance and effectiveness as well as their own preference for multidisciplinary lectures as a mode to conduct IPE. Most students agreed that challenges in conducting IPE include time constraints (83%), communication difficulties (70.8%), and lack of skills (57.4%), with no significant difference across programs. Students opined that IPE was beneficial in providing exposure to other disciplines, encouraging peer interactions, developing new skills, and improving overall learning experience. However, some reported challenges in integrating with other students, while others cited compromised experience due to problems with crowd control CONCLUSION: Students' support for IPE has positive implications for future implementation and highlights areas for improvement and further development.

The Provision of Dental Care to COVID-19 Survivors: A Concise Review.

AIMS: It has been reported that there are a certain percentage of COVID-19 patients who recover but suffer from devastating permanent organ damage or failure. Others suffer from long Covid syndrome, with prolonged symptoms that persist more than 12 weeks. However, there is scarcity of literature regarding the provision of dental treatment for these two groups of patients. This manuscript reviews the impact of multi-system involvement on the provision of dental care to these patients. MATERIALS AND METHODS: A search of literature was done in PubMed-Medline and Scopus databases to review the available literature on COVID-19 impacts on pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, and neurologic systems and respective management in dental clinical settings. RESULTS: The literature search from PubMed-Medline and Scopus databases resulted in 74 salient articles that contributed to the concise review on COVID-19 effects on pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, and neurologic systems and/or its respective dental management recommendations. CONCLUSIONS: This concise review covers the management of post COVID-19 patients with pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, or neurologic system complications.

Cross-cultural adaptation and psychometric properties of the Indonesian version of theory of planned behavior questionnaire to measure dental attendance of children with hearing loss: A pilot study.

AIMS: To translate and evaluate the validity and reliability of the Indonesian version of the Theory of Planned Behavior (TPB) questionnaire concerning mother's behavior related to children's dental attendance. METHODS AND RESULTS: The cross-cultural adaptation was tested in mothers with children aged 5-12 years old who have hearing loss. The validity and reliability of the online questionnaire were measured among 31 mothers of children with hearing loss in communities and Special School for Children with Hearing Loss in several regions in Indonesia. All indicators of attitude, subjective norms, and perceived behavior control (PBC) on mothers' behavior towards children's attendance was valid (p < .05). The overall Cronbach's alpha of the questionnaire for internal consistency was 0.773. The test-retest reliability results were based on repeated administration in the same participant mother, measured at one-week interval; the interclass correlation coefficient (ICC) was 0.903. CONCLUSION: The Indonesian version of the TPB questionnaire concerning mother's behavior related to children's oral health has shown adequate validity and reliability for investigating the dental attendance of children with hearing loss.

Impact of the special care dentistry education on Malaysian students' attitudes, self-efficacy and intention to treat people with learning disability.

INTRODUCTION: Special Care Dentistry (SCD) education has been introduced in Malaysia, but there are limited number of studies about its impact to students. Thus, this study aimed to explore the level of students' readiness to treat people with learning disability (PWLD) based on their attitudes, self-efficacy and intention to treat. METHODS: A questionnaire was developed based on the Dental Student Attitude to the Handicapped Scale, Scale of Attitudes to the Disabled Persons and Health Action Process Approach. The self-administered, validated questionnaire was tested for reliability (Cronbach's alpha = .71-.81), before being distributed to clinical dental students of both genders from two universities (University A, n = 176 and University B, n = 175). Quantitative data were analysed via t test and ANOVA (p < .05) using the SPSS software. RESULTS: There was no significant difference in mean total attitude score between the universities, although dental students from University A, who mostly reported having received hands-on clinical experience in SCD and exposure to Disability Equality Training (DET), showed significantly higher individual mean attitude score for 5 (out of 24) attitudinal items. The mean total self-efficacy score and individual mean self-efficacy score for 1 (out of 5) self-efficacy items were also significantly higher amongst University A dental students. The intention to treat PWLD was not significantly influenced by university, gender or year of study. CONCLUSION: Incorporation of SCD education in the undergraduate curriculum, with hands-on clinical experience and exposure to DET, is recommended to equip students to be efficient oral healthcare providers for PWLD.

Malaysian dental students' knowledge of managing dental trauma in children.

OBJECTIVE: This study sought to assess dental students' training and experiences in addressing traumatic dental injury (TDI), and, more specifically, their knowledge of TDI management in children. METHODS: All Year 1 to Year 5 dental students (n = 413; response rate = 72.9%) were invited to participate in an online, self-administered survey, which was based on a validated questionnaire. Quantitative data were analysed via chi-squared test (p < .05) using the Statistical Package for the Social Sciences software program. RESULTS: Only a few students were found to have undergone first-aid training in TDI (19.3%) and to have encountered TDI incidents (10.6%) before. Almost all preclinical and clinical students agreed that TDI constitutes an emergency (97.8% vs. 99.4%, respectively) and that tooth avulsion requires immediate care (97.1% vs. 99.0%, respectively). However, almost half of the students (48.8%) did not know the management protocols for a fractured tooth. Compared with clinical students, a significantly lower percentage of those in preclinical study knew the following: (1) the main cause of TDI, (2) the teeth that most commonly experience avulsion, (3) the management protocols for an avulsed tooth (e.g., handling, transportation and urgency of professional intervention) and (4) the management protocols for a fractured tooth (e.g., appropriate storage medium and need for immediate treatment). Amongst the clinical students, a significantly lower percentage of those in Year 3 knew how to transport and store avulsed and fractured teeth, and which teeth are most likely to experience avulsion. CONCLUSION: This study identified areas of TDI education in need of further refinement. Revision of the dental curriculum in terms of design, content, teaching method and delivery time may thus be warranted.

Speech and mastication difficulties following treatment by a "street dentist": A case of oral lipoma.

In this report, we present the case of a 68-year-old male patient with a complaint of mastication and speech limitations one year after the prescription of a fixed bridge and the construction of "connected" crowns by a "street dentist." A thorough oral examination revealed a multilobulated swelling in the right buccal mucosa that extended to the buccal sulcus. The lesion, which was first noticed as a small, asymptomatic swelling by the patient one year prior, seemed to have undergone enlargement since the prostheses were prescribed. The lesion was completely removed via surgical excision under general anesthesia. Histopathological examination of the excisional mass revealed mature adipocytes and features consistent with conventional or classic lipoma. This case highlights the importance of receiving dental treatment from a qualified professional, whose responsibilities include performing a thorough examination of the oral cavity during treatment planning and delivery, review appointments, and regular dental visits. Such investigation is important to allow for early disease detection and control, especially for patients with complex treatment needs as well as those who may present with asymptomatic and slow-growing lesions such as lipomas.

A case report of cleidocranial dysplasia: A noninvasive approach.

Cleidocranial dysplasia (CCD) is a rare bone disorder. The main dental features are the presence of multiple retained deciduous teeth and supernumerary teeth, as well as unerupted permanent teeth. To date, CCD is managed by a combination approach, which consists of the extraction of deciduous and supernumerary teeth, followed by orthodontic traction of unerupted permanent teeth. This case highlights the management of a girl with CCD, who refused the recommended protocol. A 15-year-old Malay female presented with a complaint of retained deciduous teeth. Intraoral examination revealed multiple retained deciduous teeth. Radiographs showed numerous impacted supernumerary and unerupted permanent teeth. The patient opted to improve her facial appearance with a less aggressive treatment option. A composite build-up on all anterior maxillary deciduous teeth was carried out until the patient was ready to undergo surgical intervention.

Perceptions of behavioural guidance techniques for paediatric patients amongst students in a Malaysian dental school.

OBJECTIVES: Behavioural guidance (BG) training is an important component of preparing future dentists to manage paediatric patients, who often exhibit cooperation issues during treatment. This study investigated the acceptance of various BG techniques amongst dental students in a Malaysian institution. METHODOLOGY: A paper-based survey was conducted, classroom-style, on all dental students (Year 1 to Year 5, n = 336, response rate = 84.5%) using a validated questionnaire, developed from previous literature. For each BG technique, students used a visual analogue scale to mark their acceptability score; this figure was later categorised into different acceptance levels. Students' mean acceptability scores and acceptance of each BG technique were consecutively analysed via independent t test and chi-square test (significance level, P < 0.01) using Statistical Package for the Social Sciences software. RESULTS: Across the academic year, most students cited acceptance of reinforcement techniques (eg positive reinforcement, encouraging child "not to be a coward", promising a toy) and desensitisation methods (eg tell-show-do, music/video distraction, stimulating the child's imagination, using euphemism), but not for aversive interventions (eg hand over mouth, using Papoose Board, active immobilisation) and showing needles (P > 0.01). Percentages of those who accepted communicative techniques involving parents demonstrated significant differences across subjects of different academic years, between pre-clinical and clinical groups of respondents and amongst clinical students. Other techniques with such significant differences, along with low acceptance, included modelling, voice control and disallowing the child to speak. CONCLUSION: The findings of this study provide useful information for curricular enhancement aimed at equipping dental students with the ability to apply appropriate and effective BG techniques during patient care.

Photodentistry - an innovative approach to improving students' empathy and learning experiences in comprehensive patient care.

OBJECTIVES: Preparing future dental school graduates to provide comprehensive patient care with empathy requires the completion of adequate training in such practice. This study was undertaken to investigate the effectiveness of the Photodentistry learning activity, which uses visual arts, in improving dental students' empathy and learning experience in comprehensive patient care. METHODS: All fourth-year undergraduate dental students (n = 69, response rate = 100%) participated in the Photodentistry learning activity developed by specialists from the areas of dentistry, arts, education, and psychology. A survey using the Toronto Empathy Questionnaire (TEQ) was conducted both pretest and posttest, followed by an open-ended written survey of their reflection towards the learning activity. Quantitative data were analyzed via paired t-test (P < 0.05), while qualitative data were analyzed using thematic analysis. RESULTS: There was a significant increase in both students' total mean empathy score and the individual scores for 8 (out of 16) items of the TEQ after the learning activity. Students stated that they had an improved understanding of managing patients in a comprehensive manner (e.g., managing medically compromised patients, performing treatment planning, communication with patients who have special health care needs). Students also reported the development of skills (e.g., observation, critical thinking) and positive attitudes (e.g., empathy, responsibility) towards patients. CONCLUSION: Photodentistry is an effective learning approach for improving dental students' empathy and learning experience in comprehensive patient care.

Stress and its relief among undergraduate dental students in Malaysia.

This study was conducted to identify the prevalence of stress, types of stressors, consequences of stress and stress relievers among undergraduate dental students at the University of Malaya during the different years of study. A descriptive cross-sectional quantitative study was conducted using a self-administered questionnaire among Bachelor of Dental Surgery students during Years 2 to 5. A 100% response rate was obtained. The instrument asked questions about the preceding academic year. The results of the questionnaire reveal the prevalence of stress was 100%. The most common cause of stress among preclinical students was academic concerns and among clinical students was patient management and clinical performance. Physical and behavioral problems were reported as consequences of stress. Most students overcame stress by having strong interpersonal relationships.