The World Health Organization (WHO) recently added more details about occupational burnout to the International Classification of Diseases. Consequently, the topic of hygiene burnout is more relevant than ever.1 A staggering percentage of hygienists (17%) fantasize about a career change at least once per month, according to a 2015 survey, and graduates after 2010 reported the least amount of job satisfaction in dental hygiene.2
It makes one wonder: Why?
New studies that utilize functional MRI (fMRI) scanning technology are beginning to answer this question. The research illustrates exactly why this phenomenon is occurring, why dental hygienists are more at risk, and what we can do to increase job satisfaction.3
In 2018, a study was performed to evaluate the human brain at rest. This brain was separated into 244 parcellations or sections in order to evaluate oxygenation levels of blood in certain parts while in a resting state. The higher levels of oxygen indicate higher levels of activation.3
The results were groundbreaking in a multitude of ways. First, this was the very first study to utilize resting-state fMRI scans to predict personality tendencies accurately. The simultaneous activation between certain parcellations helped the researchers to accurately predict omitted data from other participants in the same study. Based on the information gleaned from the fMRIs, the researchers were then able to predict patient X’s personality profile results exclusively based on their scan.3
The participants in the study were asked to complete a personality inventory (as outlined by the Oxford Handbook of Personality Assessment) before their scans were analyzed. This inventory, nicknamed the “Big Five,” categorizes a person’s personality into five major groups: openness, agreeableness, neuroticism, extraversion, and conscientiousness.4,18 The two major traits studied and strongly related to deviations in brain anatomy and activation were extraversion and neuroticism.3,18
So, what is an introvert, and what is an extrovert? Introversion is typically defined as a person’s innate desire to avoid social situations and a tendency to seek solitude.5 It is a reasonably accepted concept that an introverted person “recharges” their energy levels by avoidance of social situations while their extroverted counterparts recharge by socializing at the end of the week.5
How does this relate to neuroticism? Typically, higher levels of neuroticism or perfectionistic tendencies are associated with the introverted trait rather than the extroverted trait.6 Additionally, women are more likely to be higher on the neuroticism scale than men.7
When stimulated with negative images, the extroverted brain had more activation in the anterior cingulate cortex and was involved in anticipated reward and attention than an introverted brain.3,6 In fact, a study in 2005 indicates that activation in the anterior cingulate cortex was up to five times more accurate in predicting whether a person would approach a situation in an introverted or extroverted way than their own self-reporting would suggest.8
Paired with the newest in the fMRI scanning accuracy, this analytical trend has raised the question of whether scanning is the future of psychiatry, providing for less subjective variation than the current self-reported methods in personality testing.8
What Extroverts and Introverts Want
The introverted brain showed more connections in the area of the dorsomedial prefrontal cortex, the area most involved in moderating social behavior.3 This may indicate why extroverted people seek more social behavior as they tend to have more blood oxygenation in the very region of the brain where they obtain reward.3,8 Another study found that extroverted people report more mood elevation following a social interaction than an introvert, reinforcing this idea.5
Recent studies have also found that the typical introverted person does not fit the assumed profile of socially awkward. In fact, one study out of Duke University in 2018 suggests that in a social setting such as the cocktail hour those who rated themselves higher on the introvert scale were perceived by their conversation partners as being more socially skillful than their extroverted peers.
Introverts were also more likely to recall personal information from the interaction, indicating that introverted people may exert more effort during the social interaction to pay attention to detail.5 Additionally, those higher in neuroticism and introversion tend to have more fear of judgment in the social interaction than an extroverted person, with additional effort taken to make a “good impression” during their interactions.3,5
The brain of an introvert at rest not only has fewer activations in certain parts but deviates even more by having connections between those parts that are inconsistent with an extroverted brain.3,9 For example, the individuals with the highest extraversion tendencies seemed to show more connectivity with the amygdala and insula than the introverted brain at rest.6,10 Conversely, those lowest in the extroverted category, or more introverted, had fewer resting connections between the insula and the amygdala. This could suggest that, in order for an introverted person to engage in social interaction, they need to exert more effort to create connections between parcellations that are not innately connected at rest.3,6,10
This could theoretically be responsible for the perceived level of exhaustion an introvert experiences following a social gathering5 − not to mention that the decreased connectivity between those two regions of the brain is also associated with a higher likelihood of anxiety and depression.11,12 Additionally, those who had a higher tendency toward introversion and fear of negative evaluation have also been associated with increases in levels of cortisol or stress hormone.13
A countrywide study out of Finland surveying only dentists indicates that this new diagnosis of occupational burnout is strongly related to symptoms of major depression.14,15 While introversion has not been added to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association), it was considered back in 2012 when the newest revised edition of the DSM-V was released. It was eventually decided that introversion is not at this time categorized as any sort of disorder but rather a specific personality tendency to do things in a certain way.
At Risk for the Blues?
It still begs the question: Is burnout just depression? Or, are we simply introverted people in a highly social job, contributing to elevated cortisol levels, increased levels of fear, judgment, and anxiety in our day-to-day interactions? Are dental hygienists more at risk?
Think about the clinical setting. How many interactions throughout the day are necessary? Let’s postulate an eight-hour clinical day includes nine adult cleanings. That is nine conversations, more if there are also children or spouses in the clinical room. Let’s not forget to mention the banter during the exam with the doctor, which is another social interaction, and the conversation with the treatment coordinators at the front desk.
Now add the interactions between coworkers before or after a shift and sometimes between patients. There have even been studies that suggest a patient is more likely to schedule needed treatment if they feel a personal connection with their clinician.16 So, we have added a plentiful opportunity for social interaction, then added an additional pressure to be liked by the patient, further emphasizing the introverted brain’s tendency for fear of evaluation. Now multiply that by five days per week.
In a profession that is highly detail-oriented and, as indicated by the ADHA, 98% female, is it going to be a tremendous surprise when someone finally takes a survey to evaluate the level of neuroticism in the typical dental hygienist?17 Given the correlations between neuroticism
and introversion, how many of us will be surprised to be grouped into the introvert category?
Message to Younger Dental Hygienists
In conclusion, I want the younger generation of dental hygienists − the ones who rate their job satisfaction the lowest out of all generations of graduates − to pay attention to their own emotional health. Hygiene burnout is not limited to those suffering from musculoskeletal disorders as a result of practicing for many years.
You can be a hygienist for five years and experience a level of emotional fatigue from being an introvert in a highly social profession, and this fatigue can be just as debilitating as any musculoskeletal disorder. Mental health and psychiatry are not a soft science anymore. We have the scans to prove it.
Your brain processes differently than the hygienist in the next operatory. Lashing out at your family when you go home at night may not be the depression and constant agitation you think it is; you may be emotionally fatigued to a point you cannot handle. And it’s not your fault.
So, what is the solution?
You cannot function as a hygienist taking care of your patients until you take care of yourself. Find your comfort zone and dose of social interaction that suits your needs. For some, getting in that 12-hour day followed by a full day to recover, working only three days a week with 12-hour shifts might work for you. Perhaps those 12-hour days are far too taxing, and several short shifts may be more appropriate.
Don’t be afraid to put your emotional health first, resorting to part-time positions, if necessary. Just because you are a hygienist does not mean you have to be a hygienist full-time. Find other avenues for income. Write articles, for example. Invest in the stock market. Pursue a higher degree in order to teach hygienists at the clinical or academic level and take a break from the demands of private practice.
Life is about more than just making ends meet. Prioritize yourself and don’t feel selfish for doing it because a happy hygienist is not only a better clinician, but a better mom, wife, sister, daughter, and friend (male hygienists: substitute nouns appropriately; I haven’t forgotten about you).
- World Health Organization.Burnout an “occupational phenomenon”: international classification of diseases. (2019) Retrieved from https://www.who.int/mental_health/evidence/burn-out/en/
- Hartley, M. Career satisfaction: dental hygienists are satisfied, yet still daydream. (2015) Retrieved from https://www.dentistryiq.com/dental-hygiene/career-development/article/16350741/career-satisfaction-dental-hygienists-are-satisfied-yet-still-daydream
- Wei-Ting, H., Rosenberg, M., Scheinost, D., et al.Resting-state functional connectivity predicts neuroticism and extraversion in novel individuals. Social and Cognitive Affective Neuroscience. 2018 Feb; 13(2):224-232.
- Costa, P., McCrae, R.Personality disorders and the five-factor model of personality. Journal of Personality Disorders. 1990; 4(4), 362-371.
- Duffy, K., Helzer, E., Helzer, J., et al.Pessimistic expectations and poorer experiences: the role of low extraversion in anticipated and experienced enjoyment of social interaction. PLoS One. 2018; 13(7).
- Adelstein, J., Shehzad, Z., Mennes, M., et al.Personality is reflected in the brain’s intrinsic functional architecture. PLoS One. 2011; 6(11), e27633.
- Goodwin, R., Gotlib, I. Gender differences in depression: the role of personality factors.Psychiatry Research. 2004; 126: 135-142.
- Eisenberger, N., Lieberman, M., Satpute, A. Personality from a controlled processing perspective: an fMRI study of neuroticism, extraversion and self-consciousness.Affective and Behavioral Neuroscience. 2005; 5(2), 169-181.
- Cremers, H., Demenescu, L., Aleman, A., et al.Neuroticism modulates amygdala-pre-frontal connectivity in response to negative emotional facial expressions. NeuroImage. 2010; 49(1), 963-970.
- Adhajani, M., Veer, I., Van Tol, M., et al.Neuroticism and extraversion are associated with amygdala resting-state function connectivity. Cognitive, Affective and Behavior Neuroscience. 2014; 14(2), 836-848.
- Etkin, A., Prater, K., Schatzberg, A., et al. Disrupted amygdalar subregion functional connectivity and evidence of a compensatory network in generalized anxiety disorder.Archives of General Psychiatry. 2009; 66(12), 1361-1372.
- Kotov, R., Gamez, W., Schmidt, F., et al.Linking “big” personality traits to anxiety, depressive and substance use disorders; a meta-analysis. Psychological Bulletin. 2010; 136(5), 768-821.
- Dickerson, S., Kemeny, M. Acute stressors and cortisol responses: a theoretical integration and synthesis of laboratory research.Psychology Bulletin. 2004; 130(3): 355.
- Hakanen, J., Wilmar, S.Do burnout and work engagement predict depressive symptoms and life satisfaction? A three-wave seven-year prospective study. Journal of Affective Disorders. 2012; 141(2-3) 415-424.
- Jylha, P., Melartin, T, Isometsa, E. Relationships of neuroticism and extraversion with axis I and II comorbidity among patients with DSM-IV major depressive disorder. Journal of Affective Disorders.2009; 114:110-121.
- Stewart, M., McWhinney, I., Buck, C.The doctor/patient relationship and its effect upon outcome. Journal of the Royal College of General Practitioners. 1979; 29(199): 77-82.
- Callahan, R. ADHA Fact Sheet. Retrieved fromhttps://www.adha.org/resources-docs/72210_Oral_Health_Fast_Facts_&_Stats.pdf
- Butcher, J. (2009). Oxford Handbook of Personality Assessment. Oxford University Press.