The Association of Dentists of Peru (Colegio Odontológico del Perú, COP) gathers 22,096 active dentists of both genders. ¹⁴ For our research, we used a probabilistic sampling method considering confidence interval of 95%, 80% of power, and 5% of error. Consequently, we were able to form a definitive sample composed of 547 dentists from public and private centres ( Figure 1). The inclusion criteria covered adult dental professionals of both genders who were working during the pandemic and who voluntarily agreed to participate in the study.

For data collection, an online questionnaire was implemented using Google Forms (Google, CA, US), which included two Liker-like evaluation instruments: Palma's Work Climate Scale (SL-SPC) ^{15, 16} and the stress questionnaire developed by Marquina-Lujan & Adriazola. ¹⁷ The SL-SPC questionnaire was composed of 23 items that were grouped into four different dimensions: task importance, working conditions, personal recognition and economic benefits. The questionnaire was scored as very satisfied (>117 points), satisfied (103-116 points), average (89-102 points), dissatisfied (75-88 points), and very dissatisfied (47 or less). On the other hand, the stress questionnaire comprised a total of 36 questions organized into five dimensions: symptoms, overload or strain, cognitive-emotional aspects, habits and adaptation. This questionnaire was scored as very high (>161 points), high (120-160 points), medium (81-119 points), low (41-80 points), and very low (<40 points) stress level.

In respect of procedures, participating dentists were required to complete questionnaires distributed via e-mails and social networks such as Messenger, WhatsApp, and Facebook (Meta, CA). The answers were stored in GoogleForms, ensuring the anonymity of the 547 participating dentists. Data were coded in SPSS v24.0 (Armonk, US) where descriptive analysis was initially performed. The normality of the data was verified with the Kolgomorov-Smirnov test and we used Pearson's Chi-square test to demonstrate differences between stress level and SL-SPC dimensions. When the analysed demographic variables required a correction, the Yates correction test was used. In addition, we found the Odds ratio (OR) with the categories of “Not satisfied” and “Satisfied” for each SL-SPC dimension versus high and normal stress level. Finally, we performed a linear regression analysis in crude and adjusted model for the influential variables considering for all analyses a p-value <0.05 (significant association) and a 95% confidence interval (CI) as statistically significant.

This study followed the Helsinki guidelines ¹⁸ and was approved by the Ethics and Research Committee of Universidad Nacional Federico Villareal with Registration Certificate No. 02-2021-UIIE-EUPG-UNFV.

Firstly, the study was conducted at a critical time during the first outbreak of the COVID-19 pandemic, which provides valuable information on the influence of the crisis on job satisfaction and stress in dentists. Secondly, to the best of the authors' knowledge, this is the first Peruvian study to include a set of work and economic factors associated with stress in dentists. Although there are several Peruvian studies that have evaluated one of these variables during the pandemic, ^{19– 22} our results highlight the link between stress and working factors. Another strength is the wide demographic diversity, i.e., the dentists enrolled were of different ages, genders, marital status and working sectors, which increases the representativeness and applicability of the results in diverse contexts.

The World Health Organization (WHO) recommends a ratio of 1 dentist per 7,500 inhabitants to achieve a proper balance between supply and demand, thus ensuring an optimal relationship between the professional and the patient. ²³ However, according to data provided by the COP, there is currently approximately 1 dentist for every 600 to 700 Peruvian inhabitants. ²⁴ This figure suggests that there is an overabundance of professionals compared to the recommendations, which could generate an imbalance in dental practice. Interestingly, the presence of a greater number of dentists in relation to the population does not represent a proportional improvement in the oral health of Peruvian citizens, despite the fact that there are 41 dental schools throughout the country. ²⁵

On the other hand, it is important to consider that a career in dentistry in Peru involves significant costs for its study, and in spite of this, the remuneration is usually insufficient, while the demands in terms of working hours and professional practice are considerably high. ²⁶ In many cases, the lack of employment contracts adds to the instability of the profession. These aspects reflect a situation of instability for dental professionals in Peru, affecting not only their economic situation, but also their welfare and quality of life in terms of social protection and work-life balance.

The pandemic has had a significant impact on the provision of dental services in Peru. Since the onset of the health crisis, dentists have faced additional challenges and new restrictions, which have led to the adoption of rigorous biosecurity protocols to ensure the safety of both care providers and patients. These new guidelines have established a solid foundation for the performance of emergency and urgent treatments, incorporating practices such as the use of personal protective equipment, antisepsis of the oral cavity, and thorough disinfection measures. ²⁷ During this period, stress has increased in the general population of Latin America, ²⁸ and healthcare professionals, including dentists, have faced an additional burden on their mental health. ^{29, 30} In fact, this study aligns with several previous findings, ^{7, 19– 22, 31} demonstrating that factors such as being male, being older than 38 years, experiencing dissatisfaction with working conditions, being married or living with housemates, and working in both the public and private sectors are related to higher stress levels.

These findings are supported by several studies of Peruvian dentists. Olivera, ¹⁹ in his research which involved 362 professionals from the Peruvian Ministry of Health, revealed a moderate stress level and well-being during the pandemic. On the other hand, Mamani's study, ²⁰ which focused on 90 dentists in the Peruvian highlands, identified a low level of personal accomplishment accompanied by high stress levels and poor job performance. In a sample of 82 dentists from the northern coast of Peru, only 40% were reported to be satisfied with their work, although no direct association was found with work performance during the first outbreak of COVID-19. ²¹

Similarly, a study conducted by another group of researchers ²² with 350 dentists in the Peruvian highlands showed that 34% of the participants experienced job dissatisfaction and 67% had moderate to high levels of absenteeism. These studies together highlight the challenges and concerns that Peruvian dentists have faced in the context of the COVID-19 pandemic, addressing aspects such as stress, work well-being, job performance and satisfaction. The key points of these research offer a more complete perspective of the experiences of dental professionals in the country and highlight the importance of implementing measures to support and care for their mental health and well-being in these challenging times.

This regulation requires policy improvement and not self-regulation according to the “supply-demand” market that has been overwhelmed during the pandemic. ^{32, 33} Dentistry is essential to a society, which must reposition itself by ensuring quality of services and professional welfare, and be one of the pillars of health care. However, integrating biosecurity measures and adapting to the changing demands of care in the midst of the pandemic have posed significant challenges for dentists. ^{1, 2, 7, 8, 34} While these efforts are essential for the health of patients and staff, it is also critical to address the psychological and emotional consequences that this situation has imposed on dental professionals. Understanding these factors can guide the implementation of support and wellness strategies aimed at mitigating the negative effects of stress in this population.

Although the study encompassed a large number of dentists in Lima, the generalization of the results may be limited in other geographic populations and time points. While validated questionnaires were used, participants' subjective self-assessment of their job satisfaction and stress levels could be influenced by cognitive and emotional biases, which could affect the accuracy of the results. Finally, other factors, such as personal, family or social factors, could limit the full understanding of the observed relationships.