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Abstract

Purpose/Objectives. The aims of this study were to assess first-year dental students’ attitudes and perceptions of diaphragmatic breathing (DB) and compare students with and without performance anxiety in terms of their attitudes and perceptions of DB.

Methods. A lecture discussing a DB technique was presented to 195 students in the Operative Dentistry course at Tufts University School of Dental Medicine. Post-lecture, a 10-question survey was distributed and addressed students’ attitudes and perceptions towards DB and its potential impact in dental school, personal lives, and future careers. Results. Of the 81 surveys completed, 44 students (54%) reported having heard of DB previously; 59 (73%) reported they experience performance anxiety. Seventy-two students (89%) reported thinking that practicing DB will benefit them as practicing dentists; 71 (88%) reported they would use it if stressed in everyday life. Seventy-six (94%) reported they would be interested in using the technique before a competency exam. Students reporting performance anxiety expressed significantly greater agreement that DB is a valuable coping tool (P = .016) and willingness to participate in DB before an Operative Dentistry competency exam (P = .018). Conclusions. Teaching diaphragmatic breathing to first-year dental students may provide them with a valuable coping tool to mitigate stress and anxiety.

Keywords

dental students dental education professional behavior stress management self-regulation

“Our results not only show a willingness of dental students to participate in a DB exercise but value for the technique to support them in their careers and in their lives.”

Introduction

Dental school is a time of immense stress for most students.^1-4 The stress begins in the first year where dental students may experience moving to a new city, leaving friends and family and developing new relationships, financial hardships, and pressures upon themselves to rise to the demands of the curriculum, do well on their exams, and develop the technical skills to perform dental procedures.⁵ These pressures, compounded with the nature of the dental applicant’s qualifications of high academic achievement and excellence in undergraduate schooling, may contribute to the dental student’s pursuit to perform at a high level in dental school.⁶ The stressful dental school environment and accompanying anxiety in this environment can pose harm to these students, and in recent years it has been shown that professional students suffer from performance anxiety.^7-9 Performance anxiety is a physiologic “fight or flight” reaction that occurs in a person carrying out an activity in the public eye with fear of a poor performance.¹⁰ Performance anxiety is also a trait that refers to the anxiety states and worry conditions that are experienced prior to and during an examination.¹¹ Performance anxiety can be a debilitating experience for dental students during written exams but even more so in preclinical competency exams where hand skill control is essential to the outcome and success of the exam.

When stressful situations occur, an individual’s breathing is often affected. Breathing can become shallow, rapid, and stem more from the chest and not the diaphragm or abdomen region. Diaphragmatic breathing (DB), also referred to as abdominal breathing or belly breathing, is an evidence-based technique that utilizes slow breathing to alleviate stress and anxiety and counteracts the “fight or flight” response.^11-15 The DB technique involves the contraction of the diaphragm, an inhalation that expands the belly, and a long slow exhalation that is twice as long as the inhalation.⁷ According to Harvard Health Publishing, the way to perform DB is described as follows: “Lie on your back on a flat surface (or in bed) with your knees bent. You can use a pillow under your head and your knees for support if that’s more comfortable. Place one hand on your upper chest and the other on your belly, just below your rib cage. Breathe in slowly through your nose, letting the air in deeply, towards your lower belly. The hand on your chest should remain still, while the one on your belly should rise. Tighten your abdominal muscles and let them fall inward as you exhale through pursed lips. The hand on your belly should move down to its original position.”¹⁵ Alternatively, DB can be practiced sitting in a chair, with knees bent and the shoulders, head, and neck relaxed.¹⁵ This technique has been shown to relax the muscles of the body and produce a calming effect on the autonomic nervous system, alleviating stress and anxiety.^7,16,17 (Figure 1) Diaphragmatic breathing has also been shown to have many health benefits for inflammatory and pain responses, insomnia, PTSD, and mood disorders.¹⁸ Several studies have shown that DB has been effective in alleviating stress, anxiety, and overwhelming feelings among students as well as improving their academic learning and achievement.^7,13,19-21

Figure 1.

Benefits of diaphragmatic breathing.

Addressing the impact of performance anxiety in dental students is important to their overall well-being, success, and professional development. During times of distress, the stress hormone cortisol is released, and research has found that elevation in corticosteroid levels can impair declarative memory, concentration, and learning.^22,23 In addition, if students are unable to navigate stressful preclinical situations psychologically, they may lose confidence in themselves and possibly negatively influence future preclinical and clinical performance. Dental practice presents an array of situations and challenges that are stressful, and the dentist needs to have the skills to adapt to maintain focus and composure. The preclinical setting presents a controlled environment to practice dentistry and can be an appropriate setting for students to learn and practice coping strategies to mitigate the everyday clinical stress experienced by practicing dental professionals.

Research exploring dental student stress and performance anxiety has looked at rational coping, emotional-based coping, problem solving, and avoidance.^24-26 Though highly treatable, individuals who have suffered from performance anxiety are often reluctant to seek an intervention.²⁷ Interventions to investigate how to lower dental student performance anxiety have not been studied. The aims of this study were (i) to assess first-year dental students’ attitudes and perceptions of diaphragmatic breathing as a stress management tool after an introductory lecture and (ii) to compare the students who reported having suffered from performance anxiety to those who did not in terms of their attitudes and perceptions of diaphragmatic breathing. The hypotheses guiding this research study were that students would have positive attitudes and perceptions of DB after the lecture and that students who reported having performance anxiety would experience greater benefits of DB.

Methods

Study Design

This study was granted exempt status by the Tufts Health Sciences Institutional Review Board (STUDY 13097) and took place at Tufts University School of Dental Medicine during the fall of 2018. The principal investigator (PI), an endodontic faculty member and Registered Yoga Teacher, presented the lecture, “The Power of Breath,” to the1 predoctoral D1 class (195 students). This lecture was presented during the first week of the D1 Operative class as part of the previously planned curriculum. The learning objectives of this lecture were to (1) understand the concept and benefits of diaphragmatic breathing, (2) learn how to execute the technique, (3) practice the technique, and (4) discuss applications of diaphragmatic breathing in the academic, preclinical, and clinical settings. The PI addressed the first learning objective via a PowerPoint presentation reviewing the evidence-based science and physiology behind DB, its history, and previous applications. The second learning objective was achieved with the PI giving a demonstration of the DB technique. The students were then guided through the technique by the PI before practicing it on their own, accomplishing the third learning objective. Finally, there was an open discussion of how and when DB could be used to mitigate the stress of academic, preclinical, and clinical competency exams and in clinical practice, accomplishing the fourth learning objective.

Study Procedure

Prior to the lecture, 10 survey questions had been developed for this study (see Appendix 1) and had been pre-tested in person for content and face validity. Content validity was performed by 5 current faculty members using a five-point Likert scale to rate whether the questions should be included in the survey. Face validity was performed by 5 current D2, D3, and D4 students who were asked to review the survey and evaluate whether the questions were easily understood, simple, useful, and necessary. They were also asked whether they were comfortable answering the questions, had any trouble with the questions, and if they had any additional feedback. After the lecture, all D1 students were emailed a link to the survey, which was administered online using Qualtrics. The email was resent weekly 2 additional times, and the survey remained open for 90 days after the second reminder email. All data were collected anonymously.

Statistical Analysis

Frequency distributions (counts and percentages) were calculated for each survey question. Associations between binary variables were evaluated via Fisher’s exact test. Associations between binary and ordinal variables were evaluated via the Mann–Whitney U test. The significance level was set at α = .05. SPSS v. 26 (IBM Corp., Armonk, NY, United States) was used in the analysis.

Results

A total of 81 surveys (a response rate of 42%) were completed by the D1 class. Table 1 presents frequency distributions of the survey questions; Table 1a shows results for binary (Yes/No) questions, and Table 1b shows results for Likert scale (“Strongly Agree” to “Strongly Disagree”) questions. Among the students who responded to the survey, 44 (54%) reported hearing of the DB technique before the lecture, and 59 (73%) reported that they have performance anxiety or have suffered from it before exams. In addition, the majority of students reported that they will use DB if stressed in everyday life (88%), would be willing to participate in DB prior to an Operative Dentistry competency exam (94%), and have used DB before an exam or practical (69%). However, only 34 students (42%) reported learning how to practice this breathing skill prior to dental school (Table 1a). The majority of students strongly agreed or agreed that the DB exercise was calming (90%), that practicing DB will benefit them as practicing dentists (89%), that DB is a valuable coping tool (85%), and that DB can help them on future tests (89%) (Table 1b).

Table 1.

Frequency Distributions of the Survey Questions.

a. Questions with Binary (Yes/No) Answer Options (n = 81).
	Yes		No
Question	n	%	n	%
Heard of diaphragmatic breathing for performance anxiety prior to lecture	44	54.3	37	45.7
Have performance anxiety or suffered from performance anxiety before exams	59	72.8	22	27.2
Will use diaphragmatic breathing if stressed in everyday life	71	87.7	10	12.4
Would be willing to participate in diaphragmatic breathing prior to an operative dentistry competency exam	76	93.8	5	6.2
Have used diaphragmatic breathing before an exam or practical	56	69.1	25	30.9
Have learned diaphragmatic breathing before entering dental school	34	42.0	47	58.0

b. Questions with Likert Scale (Strongly Agree – Strongly Disagree) Answer Options (n = 81).
	Strongly Agree		Agree		Neutral		Disagree		Strongly Disagree
Question	n	%	n	%	n	%	n	%	n	%
Diaphragmatic breathing exercises are calming	48	59.3	25	30.9	7	8.6	1	1.2	0	0
The practice of diaphragmatic breathing will benefit me as a practicing dentist	49	60.5	23	28.4	8	9.9	1	1.2	0	0
Found diaphragmatic breathing in dental school a valuable coping tool	40	49.4	29	35.8	11	13.6	1	1.2	0	0
Diaphragmatic breathing can help me on future tests	44	54.3	28	34.6	8	9.9	0	0	1	1.2

Table 2 shows the results comparing students who reported having suffered from performance anxiety (n = 59) to those who reported not having suffered from performance anxiety (n = 22). Table 2a shows results for binary outcome variables, and Table 2b shows results for outcome variables on a Likert scale. Students in the group reporting performance anxiety were significantly more likely to respond positively to the question “Would you be willing to participate in diaphragmatic breathing prior to an Operative Dentistry competency exam?” when compared to the group not reporting performance anxiety (P = .018, Fisher’s exact test) (Table 2a). Additionally, those in the performance anxiety group expressed significantly greater agreement with the statement “I found diaphragmatic breathing in dental school a valuable coping tool” (P = .016, Mann–Whitney U test) (Table 2b). Other associations were not statistically significant.

Table 2.

Associations Between Self-Reported Performance Anxiety Status and Selected Survey Questions.

a. Questions with Binary (Yes/No) Answer Options (n = 81)^a
		Self-Reported Performance Anxiety
Question		Yes	No
Will use diaphragmatic breathing if stressed in everyday life	Yes	53 (89.8)	18 (81.8)
	No	6 (10.2)	4 (18.2)
	P ^b	.448
Would be willing to participate in diaphragmatic breathing prior to an operative dentistry competency exam	Yes	58 (98.3)	18 (81.8)
	No	1 (1.7)	4 (18.2)
	P ^b	.018

b. Questions with Likert Scale (Strongly Agree – Strongly Disagree) Answer Options (n = 81)^c
		Self-Reported Performance Anxiety
Question		Yes	No
Diaphragmatic breathing exercises are calming	Strongly agree	37 (62.7)	11 (50.0)
	Agree	17 (28.8)	8 (36.4)
	Neutral	5 (8.5)	2 (9.1)
	Disagree	0 (0)	1 (4.5)
	Strongly disagree	0 (0)	0
	P ^d	.271
The practice of diaphragmatic breathing will benefit me as a practicing dentist	Strongly agree	38 (64.4)	11 (50.0)
	Agree	17 (28.8)	6 (27.3)
	Neutral	4 (6.8)	4 (18.2)
	Disagree	0 (0)	1 (4.5)
	Strongly disagree	0 (0)	0 (0)
	P ^d	.124
Found diaphragmatic breathing in dental school a valuable coping tool	Strongly agree	34 (57.6)	6 (27.3)
	Agree	18 (30.5)	11 (50.0)
	Neutral	7 (11.9)	4 (18.2)
	Disagree	0 (0)	1 (4.5)
	Strongly disagree	0 (0)	0
	P ^d	.016
Diaphragmatic breathing can help me on future tests	Strongly agree	34 (57.6)	10 (45.5)
	Agree	20 (33.9)	8 (36.4)
	Neutral	5 (8.5)	3 (13.6)
	Disagree	0 (0)	0 (0)
	Strongly disagree	0 (0)	1 (4.5)
	P ^d	.228

^aNumbers are presented as frequency (column %).

^bFisher’s exact test.

^cNumbers are presented as frequency (column %).

^dMann-Whitney U test.

Discussion

Aim 1: Assessment of First-Year Dental Students’ Attitudes and Perceptions of Diaphragmatic Breathing as a Stress Management Tool After an Introductory Lecture

This study’s primary aim was to explore diaphragmatic breathing (DB) as an intervention to lower dental student anxiety and to assess student attitudes and perceptions of DB as a stress management tool after both an introductory lecture and their experience practicing the tool. In other professional school populations, research supports the need to teach students effective coping strategies to alleviate academic stress and negative performance.^13,28,29 Competency exams assess dental students’ skills to perform a clinical procedure in a set time frame and for a grade. For many students, these exams are stressful and anxiety-provoking. When students perceive an exam to be challenging or have low confidence from previous poor testing experiences, they may experience physiological symptoms consistent with the fight or flight response such as increased heartbeat, respiration rate, and blood pressure as well as muscle tension and gastric issues. Diaphragmatic breathing can be used to counteract stressful situations, as it is a technique to develop concentration and awareness and to produce a calming effect.³⁰ Ninety percent of the dental students in this study agreed or strongly agreed the DB exercise was calming. In the same vein, 89% reported feeling that DB can help them on future tests, and 94% stated that they would be willing to participate in a guided diaphragmatic breathing exercise before an Operative Dentistry competency exam. Considering that the ability to perform well in the preclinical setting is crucial to success in the clinical setting, teaching DB in the preclinical setting could provide students a foundational self-regulation skill that may support them through their clinical training. Furthermore, as Malghani et al. found that 96.3% of undergraduate dental students experience anxiety in the clinical setting,²⁶ the cumulative impact of instilling in D1 students the benefits of an effective coping tool is substantial.

We found that 54% of the students had heard of the DB technique prior to the lecture; however, only 42% reported learning how to practice this breathing skill before dental school. We learned that 69% of the students in our study reported having used diaphragmatic breathing before an exam or practical. However, these findings were based solely on self-report; it was not confirmed that the students understood the formal diaphragmatic breathing technique. The fact that a higher percentage of students reported having used DB than reported having heard of the DB technique might also suggest that some students may have used breathing as a coping mechanism without having been formally introduced to the DB technique. By receiving guided training on DB, students may build upon the common experience of informally taking conscious breaths in stressful situations, thereby enhancing their ability to calm and center themselves and fostering resilience for their future careers as dentists.

The profession of dentistry is demanding, and on top of the stresses of everyday life, it is valuable for providers to have skills to manage the difficulties of the profession. It is challenging to find the time in the dental school curriculum to teach skills to mitigate stress and anxiety, and it may be argued that it is not a priority of dental educators to do so. However, when asked if diaphragmatic breathing would be beneficial as a practicing dentist, 89% of students agreed or strongly agreed. Additionally, 85% agreed or strongly agreed that diaphragmatic breathing is a valuable coping tool, and 88% responded that they would use it in everyday life. Diaphragmatic breathing is an efficient, simple skill that can be taught in the academic environment. We found that introducing DB in the Operative Dentistry course with relevance to the stressors they will encounter as practicing dentists supported our hypothesis that D1 students would have favorable attitudes and perceptions of this intervention.

Aim 2: Comparison of Students Who Reported Having Suffered From Performance Anxiety With Those Who did Not in Terms of Their Attitudes and Perceptions of Diaphragmatic Breathing

Elliot and McGregor found that as a result of ineffective coping strategies, inadequate knowledge, and lack of awareness about the signs and symptoms of performance anxiety, some students are not able to manage their performance anxiety.³¹ Our study showed that 73% of the dental students studied reported having performance anxiety. The dental school curriculum expects students to acquire a high-volume knowledge base, perform well on academic exams, develop preclinical and clinical competency, and ultimately integrate their knowledge base contextually in patient care. It has been reported that examinations and fear of failure cause the most stress for dental students,¹ and the preclinical setting is where dental students begin to learn their technical skills and take competency exams, as well as where they are challenged to perform in a stressful situation. This is a time in dental school when performance anxiety is likely to surface. The preclinical experience and dental student success in this environment is key to preparing students to treat patients. It has been reported in the literature that dental students are more anxious than the general population, and further research suggests that dental students’ anxiety exacerbates patients’ distress during procedures.³² With our knowledge that almost three-quarters of students may have experienced performance anxiety before dental school, it may be valuable in this early juncture of their dental education to address performance anxiety with students in their first preclinical course. Additionally, it may be important to expose and teach students coping mechanisms not only to support them in the preclinical years but to build their resilience to meet the challenges of patient care, manage themselves, and ultimately ease their patients.

Our data showed that a significantly greater percentage of students with performance anxiety (98%) would be willing to participate in DB prior to an operative competency exam than students without performance anxiety (82%). Previous research has shown that students who report higher levels of performance anxiety tend to show lower grades on clinical competency exams and contextual understanding.³³ Our findings suggest a positive attitude of students with performance anxiety toward incorporating the DB intervention into the curriculum as an elective opportunity to take part in an exercise that may support them mentally and physically and allow for their best outcome on the examination. Although there was a significant difference between students with and without performance anxiety, more than 4 out of 5 students without performance anxiety still expressed willingness to participate in a DB exercise prior to an Operative Dentistry competency. The students with performance anxiety also expressed significantly greater agreement that DB is a valuable coping tool, which may suggest a positive attitude and perception toward the importance of utilizing this coping tool to mitigate performance anxiety. We did not find a significant difference between students with and without performance anxiety in terms of their perception of whether the practice of DB will benefit them as practicing dentists. However, this finding may reflect the fact that in the first year of dental school, students are very focused on academic success and not necessarily looking at the bigger picture of life after dental school and how stresses of dental school morph into the stresses of managing life in the profession. Regardless of performance anxiety status, most students reported that they would use DB if stressed in everyday life. This finding suggests that if DB is taught to dental students, they can use it and find value in it whether they have performance anxiety or not.

The notion of stress in dentistry and the importance of dentists addressing it dates back to the first code of ethics written by the American Dental Association (ADA) in 1866, which states that “the dentist should be temperate in all things, keeping mind and body in best possible health, that their patients may have the benefit of that clearness of judgment and skill which is their right.”³⁴ We find the positive attitudes and perceptions of incorporating a stress management tool in the curriculum a launching pad to consider and explore more opportunities to find space in the dental school curriculum to address the stresses of dental school, the profession, how to manage them, and the impact on their patients. The ADEA CCI 2.0 compass points toward the future need for dental educators to investigate and embrace the ever-changing world and our changing profession with innovative approaches to thinking.³⁵ We are in that changing world, and the impact of COVID-19 on dental education has further challenged us to embrace creative opportunities to teach our dental students.

The Commission on Dental Accreditation Standards for dental education programs encourages institutions to extend the scope of the curriculum to include content and instruction beyond the current boundaries of the minimum requirements. This document also defines the foundation of their standards as competency-based modalities of education in which students acquire the level of competence needed to begin the unsupervised practice of general dentistry.³⁶ Our results not only show a willingness of dental students to participate in a DB exercise but value for the technique to support them in their careers and in their lives. Although not all dental students responded positively or found value in the DB technique, the goal of teaching this intervention tool is to provide exposure to it as part of an important and useful skill set of their training early on. Even if they do not use it in school, students will have had the education and training to utilize it in their future practice and their lives.

We recognize that this study had limitations. First, its results were based on self-report at a specific moment in time. Students’ skills and knowledge about DB were not evaluated by the investigators following the lecture, and the students that participated in the survey self-identified for performance anxiety broadly, as opposed to performance anxiety prior to an exam specifically. It is also possible that some students who responded positively to the question about performance anxiety had experienced it in other domains (e.g., athletics) rather than in an educational testing environment. Furthermore, there was no follow-up to confirm whether the students who reported that they would use the DB technique if stressed in everyday life actually continued to use it. In addition, this study was performed at a single institution and with 1 class of first-year dental students; results may not generalize to other classes and institutional settings. We also recognize that of the 195 students that participated in the Power of Breath lecture, our response rate was less than 50% of the class. This is consistent with Magnuson et al.’s statement that it is difficult to obtain a high response rate in dental research with surveys.³⁷ Future research could include longitudinal studies in which students who have been trained in the DB intervention are compared with other students who have not received such an intervention. Such studies could examine whether practicing DB lowers performance anxiety and is associated with improved outcomes both in examinations and clinical practice. Further research could also examine associations between demographic variables and attitudes and perceptions of DB. These efforts would have the potential to enhance coping and resilience-building skills among dental students, with the ultimate goal of improving patient care.

Conclusion

Teaching diaphragmatic breathing to first-year dental students may provide them with a useful and accessible technique to mitigate stress and anxiety. Students with performance anxiety may be especially likely to find diaphragmatic breathing a valuable coping tool and to be willing to participate in it prior to a competency exam. Regardless of performance anxiety status, students reported positive attitudes and perceptions about diaphragmatic breathing, indicating that embedding this diaphragmatic breathing intervention into the first-year curriculum could be beneficial to all types of students.

Supplemental Material

Supplemental Material - Diaphragmatic Breathing and Performance Anxiety in Dental Students

Supplemental Material for Diaphragmatic Breathing and Performance Anxiety in Dental Students by Christina D. Pastan, DMD, Steven Eisen, DMD, Matthew Finkelman, PhD, Robyn White, BA, Sarah Pagni, MPH, PhD, and Gerard Kugel, DMD, MS, PhD in American Journal of Lifestyle Medicine

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Christina D. Pastan

Supplemental Material

Supplemental material for this article is available online.

References

Ahmad

Md Yusoff

Abdul Razak

. Stress and its relief among undergraduate dental students in Malaysia. Southeast Asian J Trop Med Publ Health. 2011;42:996-4.

Silverstein

Kritz-Silverstein

. A longitudinal study of stress in first-year dental students. J Dent Educ. 2010;74(8):836-8.

Elani

Allison

Kumar

Mancini

Lambrou

Bedos

. A systematic review of stress in dental students. J Dent Educ. 2014;78(2):226-2.

Sanders

Lushington

. Sources of stress for Australian dental students. J Dent Educ. 1999;63(9):688-7.

Murphy

Gray

Sterling

Reeves

DuCette

. A comparative study of professional student stress. J Dent Educ. 2009;73(3):328-7.

Westerman

Grandy

Lupo

Mitchell

. Relationship of stress and performance among first-year dental students. J Dent Educ. 1986;50(5):264-7.

Nemati

. The effect of pranayama on test anxiety and test performance. Int J Yoga. 2013;6(1):55.

McConville

McAleer

Hahne

. Mindfulness training for health profession students-the effect of mindfulness training on psychological well-being, learning and clinical performance of health professional students: A systematic review of randomized and non-randomized controlled trials. Explore. 2017;13(1):26-5.

Lateef Junaid

Auf

Shaikh

Khan

Abdelrahim

. Correlation between academic performance and anxiety in medical students of Majmaah University - KSA. J Pakistan Med Assoc. 2020;70(5):865-8.

10.

McGraw-Hill Concise Dictionary of Modern Medicine . Performance anxiety. 2002. https://medical-dictionary.thefreedictionary.com/performance+anxiety. Accessed April 30, 2022.

11.

Chen

Huang

Chien

Cheng

. The effectiveness of diaphragmatic breathing relaxation training for reducing anxiety. Psychiatr Care. 2017;53(4):329-6.

12.

Hopper

Murray

Ferrara

Singleton

. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: A quantitative systematic review. JBI Database System Rev Implement Rep. 2019;17(9):1855-6.

13.

Consolo

Fusner

Staib

. Effects of diaphragmatic breathing on stress levels of nursing students. Teach Learn Nurs. 2008;3(2):67-1.

14.

Anxiety disorders: taking control of persistent worries, fears, and phobias. Mayo Clin Women’s Healthsource 2005;(Suppl):1-8.

15.

Harvard Health Publishing . Learning diaphragmatic breathing. 2016. https://www.health.harvard.edu/healthbeat/learning-diaphragmatic-breathing. Accessed March 8, 2023.

16.

Kim

Roth

Wollburg

. Effects of therapeutic relationship, expectancy, and credibility in breathing therapies for anxiety. Bull Menninger Clin. 2015;79(2):116-130.

17.

Subbalakshmi

Adhikari

Shanmugavel Jeganathan

. Comparative study on cardiac autonomic modulation during deep breathing test and diaphragmatic breathing in type 2 diabetes and healthy subjects. J Diabetes Investig. 2014;5(4):456-463.

18.

Hamasaki

. Effects of diaphragmatic breathing on health: A narrative review. Medicines (Basel). 2020;7(10):65.

19.

Rygiel

. Deep diaphragmatic breathing: a “Portable Intervention” for stress reduction among university students. In: Cakmur

, ed. Effects Stress Hum. Health. London, UK: IntechOpen; 2019. [Internet].

20.

Matthews

Quinn

. Relaxation training: A humanistic technique to increase achievement. J Humanist Educ Dev. 1987;25:112-1.

21.

Benson

Wilcher

Greenberg

, et al. Academic performance among middle-school students after exposure to a relaxation response curriculum. J Res Dev Educ. 2000;33(3):156-5.

22.

Lupien

McEwen

. The acute effects of corticosteroids on cognition: Integration of animal and human model studies. Brain Res Brain Res Rev. 1997;24(1):1.

23.

Kirschbaum

Wolf

May

Wippich

Hellhammer

. Stress- and treatment-induced elevations of cortisol levels associated with impaired declarative memory in healthy adults. Life Sci. 1996;58(17):1475-3.

24.

Crego

Carrillo-Diaz

Armfield

Romero

. Stress and academic performance in dental students: The role of coping strategies and examination-related self-efficacy. J Dent Educ. 2016;80(2):165-2.

25.

Prinz

Hertrich

Hirschfelder

de Zwaan

. Burnout, depression and depersonalisation–psychological factors and coping strategies in dental and medical students. GMS Z Med Ausbild. 2012;29(1):Doc10.

26.

Malghani

Abbasi

Majeed

Saleem

. Level of anxiety in clinical settings and coping mechanisms used by dental undergraduate students to overcome it. J Dent Educ. 2021;85(11):1749-5.

27.

Powell

. Treating individuals with debilitating performance anxiety: An introduction. J Clin Psychol. 2004;60(8):801-8.

28.

Mosley

Perrin

Neral

Dubbert

Grothues

Pinto

. Stress, coping, and well-being among third-year medical students. Acad Med. 1994;69(9):765-7.

29.

Lee

Graham

. Students’ perception of medical school stress and their evaluation of a wellness elective. Med Educ. 2001;35(7):652-9.

30.

Paul

GEB

Elam

Verhulst

. A longitudinal study of students perceptions of using deep breathing meditation to reduce testing stresses. Teach Learn Med. 2007;19(3):287-2.

31.

Elliot

McGregor

. Test anxiety and the hierarchical model of approach and avoidance achievement motivation. J Pers Soc Psychol. 1999;76(4):628-4.

32.

Freeman

. Dental students as operators: Emotional reactions. Med Educ. 1985;19(1):27-3.

33.

Sanders

Lushington

. Effect of perceived stress on student performance in dental school. J Dent Educ. 2002;66(1):75-1.

34.

Code of dental ethics 1866. J Am Coll Dent 2015;82:18.

35.

Palatta

Kassebaum

Gadbury-Amyot

, et al. Change is here: ADEA CCI 2.0—a learning community for the advancement of dental education. J Dent Educ. 2017;81(6):640-8.

36.

Commission on Dental Accreditation . Accreditation standards for dental education programs. 2022. https://coda.ada.org/∼/media/CODA/Files/predoc_standards.pdf?la=en. Accessed July 5, 2022.

37.

Magnuson

Jain

Roomian

Pagni

Tran

Finkelman

. Conducting surveys in dental education research: guidelines and reminders. J Dent Educ. 2020;84(3):283-9.

Supplementary Material

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