Is examining children and adolescents with autism spectrum disorders a challenge?-Measurement of Stress Appraisal (SAM) in German dentists with key expertise in paediatric dentistry.

OBJECTIVES: This questionnaire-based validation study investigated if the dental examination of children and adolescents with autism spectrum disorder is viewed by dentists with key expertise in paediatric dentistry as a challenge or a threat in terms of transactional stress theory. The Stress Appraisal Measure (SAM) was used for this purpose and it's feasibility and validity was examined as a first part of a multi-stage process for validation in dentistry with a sample of German dentists. It has hardly been investigated how the treatment of children and adolescents with a disorder from the autism spectrum is perceived by dentists.
METHODS: An online-based survey (39 questions) plus the SAM as an add-on as well as a preceding short story of imagination on the topic (appointment for a dental check-up in a special school) were developed. Via e-mail members of the German Society of Paediatric Dentistry (DGKiZ) received a link which enabled interested members to participate. The majority of the members of the DGKiZ have additional qualifications in the treatment of children and adolescents and further training in the area of special needs care in dentistry. The data analysis was based on the SAM and its subscales.
RESULTS: Out of the 1.725 members of DGKiZ 92 participants (11 male, 81 female) fully completed the questionnaire and the SAM. All in all the dentists rated their own psychological and physical stress in course of treating children and adolescents with a disorder from the autism spectrum between less and partly stressful. Although the structure of the SAM could not be fully mapped by means of a factor analysis, the different ratings "challenge" or "threat" could be comprehensibly evaluated after reading the story. The participants rated the situation from the story in general as challenging but not as threatening. Intercorrelations between the subscales of the SAM (e.g threat and centrality) of r = .56 showed that the scales are not clearly independent of one another. According to the transactional stress model, the SAM bases on, stress (perceived stressfulness) arises from appraisal processes (e.g. threat, controllable-by-self) that bring about a comparison between the requirements for the described situation and one's own possibilities in terms of a person-environment-fit. In the hierarchical regression a variance of R2 = .48 could be explained with all six subscales (appraisal processes) to predict perceived stressfulness of the SAM within a sample of dentists.
CONCLUSIONS: Due to the response rate the results of the SAM are not representative for all German dentists, but it offers an insight into topics of special needs dentistry in Germany that have not yet been examined. Overall, the feasibility and validity of the SAM in the context of mapping cognitive appraisal processes and stress could be confirmed. Taking into account the result that the treatment of children and adolescents with autism spectrum disorder is seen as a challenge, it is concluded that there is a need to improve the education of dental students and graduated dentists in Germany in the field of special needs dentistry.

Introduction

In recent years, intensive efforts have been undertaken in Germany to improve dental care by and for people with disabilities [1]. In 2009 the Federal Republic of Germany ratified the Convention on the Rights of Persons with Disabilities (UN CRPD). With reference to Article 25 of the UN CRPD, the quality of medical care for people with disabilities must no longer differ from the quality of care for people without disabilities [2].

Furthermore, health services and interventions that meet the specific needs of individuals with disabilities have to be provided [2]. However, studies often indicate that people with intellectual disabilities in all age groups around the world have poorer oral health compared to the general population. This state of oral health is determined, for example, by an increased proportion of tooth loss, a poorer periodontal health and a lower proportion of restored teeth [3-5]. This finding also applies to people with intellectual disabilities from Germany [6,7]. A variety of reasons is given for this finding.

On the one hand, patient-related parameters, such as the lack of cooperation and communication, as well as inadequate hygienic ability or the need for supportive oral care, are described [8]. On the other hand, health policy and legal conditions of each state provide the framework for e.g. infrastructure, dental fees and remuneration, but also for dental teaching and university education [9]. The national and international literature described that there is an association between the professional training of dentists and how they feel when treating people with disabilities [9-13]. A study among dentists from Germany found that their subjective strain was significantly higher, the more insufficient and incomplete their own specialist knowledge on the treatment of children with disabilities was stated [13]. Alongside the treatment of children and adolescents with disabilities, treating individuals with mental health disorders and neurodevelopmental conditions such as autism spectrum disorders (ASD) [9,14-16] are mostly seen and described as a challenge [10,13,15,16]. However, there is sparse scientific data based on whether the perception of dentists actually corresponds to a challenge from a psychological point of view. Furthermore, there are only a few studies that show which validated survey method can be used to examine stress experiences in dentistry. These studies used, for example, either objective parameters for measuring stress [17] or instruments for self-assessment [18]. Often multidimensional questionnaires are used to measure stress appraisal and stress coping [19], which contain self-descriptions of situation-specific coping thoughts or actions [20]. Examples of this are the „Ways of Coping Questionnaire“—WAYS - [21,22] or the „Coping Operations Preference Enquiry“—COPE - [23,24]. Another example is the Stress Appraisal Measure—SAM–that captures stress perceptions based on currently occurring, cognitive processing mechanisms in coping with acute stress [25,26]. These three questionnaires are based on the transactional stress theory according to Lazarus and Folkman [27,28], whereby the COPE also uses the self-regulation model of Carver and Scheier as a theoretical basis [29]. While the WAYS and COPE questionnaires ask about situational coping processes or coping strategies, the SAM focuses on a current event and has a clear subdivision of the various control options of the respondent [26]. The SAM has already been translated into German and was examined for validation [26]. In recent years the SAM has also been translated into other languages, as several international publications show [30,31]. Various international scientific author groups used the SAM, e.g. to investigate stress perceptions and stress appraisal during childbirth [31] or currently with regard to the COVID-19 pandemic [32,33].

The purpose of the present study was to check the assumption of whether a dental examination of children and adolescents with ASD is viewed by dentists as a challenge. For this purpose, the question of how physically or psychologically stressful dentists perceive the treatment of these children and adolescents was examined. Do the dentists assess this type of treatment more as a challenge or even as a threat in terms of transactional stress theory? In addition, the validity of the SAM’s usefulness as a survey tool for recording and measuring stress perceptions and stress appraisal based on a dentist sample is examined.

Materials and methods

The questionnaire based cross-sectional survey

The presented cross-sectional study is based on a data set that was obtained as part of the online survey SoSci (SoSci Survey GmbH; Munich; Germany) among members of the German Society of Paediatric Dentistry (DGKiZ) between August and October 2020. Prior to the start of the study, a positive vote for carrying out the survey was obtained from the board of the DGKiZ. Subsequently, the invitation and the link to participate anonymously in the questionnaire based study was sent to all DGKiZ members (n = 1.725) via an e-mail sent by the DGKiZ board. As a result, it was not possible for the study group to draw personal conclusions about the participants in compliance with data protection regulations. Prior to answering the first question in the electronic file, the participants had to confirm that their participation was voluntary, to declare their consent and to state that they were 18 years or older. Furthermore, the board of the DGKiZ had given consensus to the publication of the data. Since the data collection was planned in accordance with the European General Data Protection Regulation and represents an expert survey, a formal application to the responsible ethics committee of the Witten/Herdecke University was not performed before the start of the project. Instead, we received written confirmation of the ethics committee of Witten/Herdecke University that there was no need for professional advice and for ethical approval in the case of anonymous surveys among employees in the healthcare sector. At this point, it is necessary to refer to a multicenter project whose results have already been published and which is methodically based on the same regulations [32].

The first part of the questionnaire was developed by the authors and comprised a total of 39 questions and was designed containing a hybrid of 5 open and 34 closed questions. In order to be able to compare the results, the development of the questionnaire was based on previous national and international studies [9,10,13,15,16]. In addition to various demographic aspects (e.g. age, gender, years of employment), the questionnaire aimed at exploring how the dental treatment of children and adolescents with various types of disabilities respectively neurodevelopmental or psychoemotional disorders is experienced by the respondents. Therefore, personal experiences and assessments, with regard to e.g. subjective burden were asked to rate on a 5-point Likert scale from 1 "not at all stressful" to 5 "very stressful".

Another focus was on mapping one’s own stress perception and stress appraisal in an examination of children and adolescents with an autism spectrum disorder (ASD). The German version of the SAM was used as a survey tool for this purpose [26]. The SAM was added to the questionnaire mentioned above at the end of the online survey as an add-on. With the help of the SAM, stress was induced with a preceding short story read by the study participant. The story allows the participant to imagine an appointment for a dental check-up in a special school for children and young people with intellectual or psychoemotional development disorders. The participants were asked to imagine how they would attend this school as a dentist. The situation was described as very confusing and chaotic and ended with the first patient with an autism spectrum disorder throwing himself on the floor before the dental exam began.

After reading the short story, the respondents were asked to answer the SAM’s questions. The originally English language SAM [25] is a questionnaire with 28 items, divided into seven subscales consisting of four items per scale. This measures cognitive processing mechanisms and perceived stressfulness in the event of acute stress [26]. The authors of the SAM see the transactional stress model as the basis of their questionnaire [34,35]. According to this model, stress arises from appraisal processes that bring about a comparison between the requirements for the described situation and one’s own possibilities in terms of a person-environment-fit. The perception of stress varies depending on how the situation is assessed and which forms of coping are used [36]. According to the transactional stress model, a situation is perceived as irrelevant, positive or stressful in an initial appraisal. If experienced as stressful, the person is asked to distinguish whether they consider the situation to be challenging, threatening or perceived as important. In the second appraisal, the person assesses whether they have sufficient resources of their own or whether there are other options to cope with the situation. The SAM is sub-divided in the following subscales: challenge (the situation is assessed positively, in the sense that it is manageable), threat and centrality (effects and consequences of the situation) for the first appraisal of the situation. For the second appraisal, an assessment is made of one’s own controllability, controllability by others and the uncontrollability of the situation (subscale 4 to 6). In addition, there is the “overall perceived stressfulness” scale, which can be viewed as a consequence of the previous appraisal of the situation. The perceived threat and centrality of a situation are seen as the most important predictors for the perception of stress [25]. This scale division was used adopted without exception in the German version [26].

Data analysis

In two of the three studies published by Peacock and Wong, a five- or six-factor solution of the appraisal scales was given when testing the construct validity in factor analyzes. In other studies a five-factor solution was described [26,30,31]. To verify the factor structure [25], a main axis analysis with an oblique rotation (promax rotation) was carried out in the present study after analyzing the suitability of the data. In the further course of the data analysis, the items of the seven subscales of the SAM, assessed using a 5-point Likert scale from 1 “not at all” to 5 “completely”, were combined into a non-weighted index by a calculated average. The seven subscales “threat”, “centrality”, “controllable-by-self”, “controllable-by-others”, “uncontrollable”, “challenge” and “stressfulness” were examined for their scale characteristics in the present study. The Cronbach’s α coefficient was determined to check the internal consistency of the items on a scale. According to Bühner [37] a general assessment of the internal consistency of a scale is difficult, although the information provided by Fisseni [38] for the assessment of test parameters and quality criteria can provide an orientation. According to this, values <0.80 are to be assessed as low, values between 0.80–0.90 as average and values >0.90 as high. Furthermore, Pearson correlations between the seven subscales were determined. In addition, the predictability of the “stressfulness” was verified using the six appraisal scales in a hierarchical regression. The regression examined whether the “stressfulness” can be predicted using the six appraisal scales, and how high the respective predictive value of the individual predictors is. The relevant predictors were included in the regression model for predicting the”stressfulness” according to the importance of their predictive power [25,26]. The data analysis was carried out with the statistical program SPSS Version 25 (IBM SPSS Statistics 25; IBM Corporation; New York; NY; USA). When exporting data to SPSS, serial numbers are generated from the participations in SoSci Survey. Duplicate entries were detected using the serial number and excluded from the analysis. Cases with missing values in the SAM subscales or in the other questions were excluded from the data analysis. An overview of the data analysis is given in Fig 1.

Fig 1

Data analysis.

Notes: SAM, Stress Appraisal Measure [25], German version by [26].

Results

Study participants

The response rate in relation to all 1.725 e-mails that had been sent out to members of the DGKiZ was thus 11.1% for all questionnaires started (n = 192), and 5.3% for the fully completed questionnaires. In total 92 participants (11 male; 81 female) completed the questionnaire designed by the study team and as well as the SAM. The majority of the participants were between 35 and 64 years old (n = 65; 71%). Furthermore, the majority of the participants (n = 50; 54.3%) stated that they had more than 16 years of professional experience. Further demographic information and details of the study participants are presented in Table 1.

Table 1

Study participants, frequencies and percentages.

Study participants, n = 92
	n	Percent
Male	11	12.0%
Female	81	88.0%
Age (in years and in age groups)
under 35 (all)	23	25.0%
under 35 (male)	4	4.3%
under 35 (female)	19	20.6%
from 35 to 44 (all)	21	22.8%
from 35 to 44 (male)	1	1.1%
from 35 to 44 (female)	20	21.7%
from 45 to 54 (all)	36	39.2%
from 45 to 54 (male)	4	4.4%
From 45 to 54 (female)	32	34.8%
From 55 to 64 (all)	8	8.7%
From 55 to 64 (male)	1	1.1%
From 55 to 64 (female)	7	7.6%
65 and older (all)	4	4.3%
65 and older (male)	1	1.1%
65 and older (female)	3	3.2%
Working arrangement a
Alone in his/her own practice	39	42.4%
Employed in private practice as a dentist	27	29.3%
Employed in a private practice as assistant dentist	2	2.2%
Employed in a dental school at the university	10	10.9%
Employed in a medical care center	12	13.0%
Employed in a hospital or clinic at the university	3	3.3%
others (e.g. students, persioner)	4	4.3%

a Multiple answers were possible.

Assessment of personal psychological and physical stress

When asked how stressful the dentists rate their own psychological stress in course of treating children and adolescents with ASD, the answer options 1 “not stressful at all” to 5 “very stressful” averaged 2.74 (SD ± 1.06). The assessment of one’s own physical stress when treating children and adolescents with ASD yielded a mean of 2.58 (SD ± 1.13). Overall, the assessments of both the psychological and the physical stress ranged between less stressful and partly.

„Stress Appraisal Measure”(SAM)

Factor structure and factor loadings of the SAM

The principal axis analysis with Promax rotation was carried out with seven factors to be extracted, analogous to the SAM questionnaire. An eigenvalue >1 as a criterion for the number of factors to be interpreted was not given due to the average reliability of the items. The Bartlett test for sphericity was significant (p < .01), indicating that the items correlate well with one another. The Kaiser-Meyer-Olkin coefficient as a measure of sample suitability was .80. Since this value was above the lower limit of .50, a factor analysis could be carried out [37]. We have to qualify that the reliability of a factor analysis depends on the sample size, but also the factor loadings matters [39]. Guadagnoli and Velicer stated that “If a solution possesses components with only a few variables per component and low component loadings, the pattern should not be interpreted unless a sample size of 300 or more observations has been used.” [40]. So we carried out the factor analysis, taking into account the factor loadings on the individual factors due to our small sample.

Due to the structure of the SAM questionnaire, seven factors were extracted that can explain 56% of the total variance before the rotation. After the rotation, the first factor alone could explain 19% and the second factor 22%, the remaining factors 15%, 15%, 16%, 8.25% and 5% of the total variance. However, since the factors correlate with one another, the total variance of all factors cannot be totaled. Table 2 illustrates the sample matrix after the factor analysis.

Table 2

Pattern matrix principal axis factoring promax rotation–Items SAM.

	Factor
	1	2	3	4	5	6	7
SCALE 1 Item 5 feel anxious a	0.61	0.03	-0.02	-0.03	0.40	-0.07	0.07
Item 11 outcome negative	0.03	-0.29	0.03	0.13	0.42	0.03	-0.03
Item 20 threatening situation	0.38	-0.01	0.23	0.22	0.26	0.22	-0.20
Item 28 negative impact	0.03	-0.07	0.02	0.77	-0.10	-0.12	-0.31
SCALE 2 Item 6 Important consequences	0.03	0.00	0.05	0.75	0.19	-0.01	0.38
Item 9 Will be affected	0.70	-0.10	0.03	0.07	-0.25	-0.11	0.03
Item 13 serious implications	0.06	0.20	-0.02	0.63	0.12	-0.04	-0.14
Item 27 long-term consequences	0.34	0.08	-0.11	0.55	-0.23	0.01	0.16
SCALE 3 Item 12 Have ability to do well	-0.15	0.74	0.02	0.09	-0.10	-0.03	-0.12
Item 14have what it takes	-0.04	1.09	-0.22	0.06	0.09	0.10	0.04
Item 22 Will overcome problem	0.09	0.43	0.19	0.02	-0.28	-0.04	0.18
Item 25 have skills necessary	-0.07	0.86	-0.03	0.05	0.06	-0.09	0.07
SCALE 4 Item 4someone I can turn to	-0.16	-0.29	0.95	0.13	-0.14	0.01	0.03
Item 15help available	-0.04	0.35	0.62	-0.08	0.17	0.04	0.03
Item 17 resources available	-0.19	0.39	0.27	-0.05	0.14	-0.10	0.04
Item 23 anyone who can help	0.06	-0.08	0.71	-0.13	0.04	-0.07	0.27
SCALE 5 Item 3 outcome uncontrollable	-0.09	0.12	-0.04	-0.01	0.62	0.03	-0.06
Item 1 totally hopeless	0.00	-0.15	-0.03	0.04	0.73	-0.09	-0.03
Item 18 beyond anyone’s power	0.02	0.01	-0.01	-0.05	-0.03	0.90	0.03
Item 21 problem unresolvable	-0.26	-0.09	-0.00	0.50	0.04	0.33	0.04
SCALE 6 Item 7 positive impact	-0.10	-0.01	0.17	-0.15	-0.06	0.08	0.47
Item 8 Eager to tackle	0.30	0.29	0.39	-0.05	-0.25	0.05	-0.06
Item 10 Can become stronger	0.16	0.17	0.10	0.11	-0.11	-0.04	0.39
Item 19 Excited about outcome	0.85	0.05	0.08	-0.04	0.01	0.15	0.00
SCALE 7 Item 2 tension caused by the situation	0.56	-0.18	-0.06	-0.11	0.25	-0.13	-0.02
Item 16 resources put to the test	0.40	-0.08	-0.20	-0.11	-0.03	0.23	0.10
Item 24 stressful situation	0.55	-0.03	-0.09	0.14	0.00	-0.02	-0.18
Item 26 Efforts to cope with	0.32	-0.05	-0.10	0.08	-0.12	-0.07	0.07

Notes: threat = scale 1; centrality = scale 2; controllable-by-self = scale 3; controllable-by-others = scale 4; uncontrollable = scale 5; challenge = scale 6; perceived stressfulness = scale 7, SAM, Stress Appraisal Measure, [25]., German version by [26].

Factor extraction: Principal Axis Factor Analysis.

Method of factor rotation: Promax with kaiser normalization.

a. The rotation has converged in 8 iterations.

Table 2 shows the following results:

Subscale “threat” scale 1: Two of the four items in the “threat” subscale have the highest load on factor 1, item 11 has the highest load on factor 5 and item 28 has the highest load on the fourth factor.

Subscale „centrality”scale 2: Three of the four items load the highest at factor 4, item 9 load the highest at factor 1.

Subscale „controllable-by-self”scale 3: All four items load the highest on the second factor.

Subscale „controllable-by-others”scale 4: Three of the four items load the highest on factor 3, item 17 load on the second factor the highest.

Subscale „uncontrollable-by-anyone”scale 5: Two items load the highest on the 5th factor, item 18 on the 6th factor, item 21 on the 4th factor.

Subscale „challenge”scale 6: Two items load the highest on the 7th factor, item 8 on the 3rd factor, item 19 on the first factor the highest.

Subscale „overall perceived stressfulness”scale 7: All 4 items load the highest on the 1st factor.

Psychometric properties of the SAM subscales

The reliability of the subscales, measured using the Cronbach’s α, was shown as follows: "threat": α: .69, "centrality": α: .76, “controllable-by-self ": α: .89, "controllable-by-others ": α: .82, “uncontrollable-by-anyone” α: .56. The subscale “challenge” had insufficient reliability with all four items (α: .33), especially item 19 “excited about outcome” correlated negatively with two items on its own scale. The subscale “overall perceived stressfulness” had an internal consistency of α: .66.

Intercorrelations of the SAM subscales

The subscales formed [25] do not show a relative independence of the individual subscales from one another in all cases according to the available intercorrelations (Table 3). The “threat” subscale, for example, has a strongly positive correlation with the “centrality” and “uncontrollable” of the situation. In addition, the subscale “controllable-by-self” has a highly positive correlation with “controllable-by-others”.

Table 3

Intercorrelations of the SAM subscales.

	1	2	3	4	5	6
1 threat
2 centrality	.56
3 controllable-by-self	-.62	-.23
4 controllable-by-others	-.43	-.28	.51
5 uncontrollable	.50	.27	-.51	-.36
6 challenge	-.01	.21	.31	.36	-.14
7 perceived stressfulness	.63	.48	-.51	-.43	.32	.01

Notes: n = 92.

SAM = Stress Appraisal Measure, (5-point Likert scale from 1 “not at all” to 5 “completely”), [25], German version by [26].

As expected, the “overall perceived stressfulness” correlates highly positively with the subscales “threat”, “centrality” and “uncontrollable” and highly negative with “controllable-by-self” and “controllable-by-others”. The assessment of the situation as challenging is not related to the assessment of the situation as threatening (r = -.01).

Prediction of the overall perceived stressfulness

For the hierarchical regression to predict the “overall perceived stressfulness” by the six other subscales, several preconditions were checked. The precondition, that the residuals are normally distributed [39], was checked using the Q-Q plot. The result of the residual test of the dependent variable “overall perceived stressfulness” showed no deviation from the normal distribution. The Shapiro-Wilk test as a test for normal distribution of the residuals indicates that the distribution of the scores is not different from a normal distribution (p = .17). The homoscedasticity, defined as the independence of the scatter of the measurement errors, was checked via the Breusch-Pagan test. The null hypothesis of this test is that there is homoscedasticity (p = .26). Multicollinearity describes the correlation between the predictors being so high that the estimation of the individual coefficients is deemed inaccurate [39]. A test function for multicollinearity is the Variance Inflation Factor (VIF). Values greater than 10 are considered problematic [41]. The values of the VIF were all well below 10 indicating no multicollinearity.

To calculate hierarchical multiple regression, variables were included according to the importance of their predictive power. When predicting “stressfulness”, the “threat” subscale (in the first model) and the “centrality” subscale (in the second model) were included. In the third model, all four other subscales were recorded. It was found: a) in the first model, a high degree of variance explanation of the „stressfulness” through the perception of the threat of the situation (β = .64, R = .41, p < .01). b) By adding the “centrality” subscale in a second model, the influence of the new predictor (p < .10) on the β-weight of “threat” was confirmed. The β-weight of the “threat” decreased slightly (β = .54 instead of .64) and both subscales had an explanation of variance of R = .43. c) When adding the remaining four subscales in a third model, a negative influence of the predictors “controllable-by-self” (β = -.21, p < .10) and a non-significant negative effect of the subscale “controllable-by-others” (β = -.17) can be confirmed. The subscales “uncontrollable-by-anyone” and “challenge” did not explain any significant variance. The total explained variance of the third model shows an R of .48.

The short story

The mean values of the seven SAM subscales given by the participants after having read the short story are shown in Table 4.

Table 4

SAM subscales-mean values and standard deviations.

Scale	Mean value	Standard deviation
threat	1.47	0.55
centrality	1.68	0.70
controllable-by-self	3.82	0.84
controllable-by-others	3.38	0.97
uncontrollable	1.75	0.68
challenge	2.97	0.63
perceived stressfulness	2.68	0.76

Notes: n = 92.

SAM = Stress Appraisal Measure, [25], German version by [26].

The participants rated the given situation on average less as threatening but more as challenging. They also found the scenario to be less significant for them in terms of its consequences and effects. In addition, they were more positive about coping with the problem due to their own skills and possibilities. The same applied to the perspective of whether there were enough resources and skills available from the other side to cope with the situation.

Discussion

When the dentists with key expertise in paediatric dentistry were asked in our study how they assessed their psychological and physical stress in course of treating children and adolescents with autism spectrum disorders (ASD), they indicated to perceive a less stressful or moderate psychological stress. This was also true in regard to physical stress. Previous studies dealt with the question of how challenging the treatment of children and adolescents with ASD is for dentists. These were either concrete challenges such as the behavior of children [42] or the need for information or further training on the subject or practical recommendations for action [11,14,15].

Studies about psychological and physical stress and the resulting stress experience of dentists when treating children and adolescents without disabilities showed that there is an association between the stress or stress experience and the practical experience of dentists, the procedures used and the age of the patient [43-45]. In terms of practical experience, the emphasis here is primarily on expertise in dealing with patients with ASD [46]. According to an US study, one suggestion for improving knowledge and practical experience in this area would be interdisciplinary cooperation with professions such as occupational therapy or psychology [47]. Since the majority of our study participants already had a professional experience of more than 16 years (n = 50, 54.3%), practical experience in dealing with patients with ASD may also have been a decisive factor here for the rather low exposure values. It should also be noted that the majority of respondents were female dentists. Most of the participants (men and women) were between 45 and 54 years old. The age and therefore the associated professional experience, as noted above [43], and possibly also gender [45] can have an influence on personal psychological and physical stress.

The internal consistencies of six of the seven scales were between 0.56 and 0.89. According to Fisseni, the subscales “controllable-by-self” and “controllable-by-others” showed an average reliability [38]. The other subscales showed low reliability. The subscale “uncontrollable”, comparable to studies 1 and 3 [25], only has an internal consistency of 0.56. The “challenge” scale in Delahaye et al. had an α value of 0.57 [26]. In our study, the internal consistency is even lower (α: 0.33). Mainly because of the negative correlations with two items on our own scale, item 19 could have been excluded from the further analyzes. However, since the full SAM tool was to be investigated, this possibility was abandoned. Not all of the Peacock and Wong factors could be replicated with the principal axis analysis [25]. An examination of the factorial validity and dimensionality of the SAM favors, for example, a 4-factor solution of the appraisal scales and criticizes the partly redundant factors as well as the low internal consistency of the factors in the original study [48]. The “overall perceived stressfulness” (factor 1) and “controllable-by-self” (factor 2) could be replicated in our study with the respective four items. Item 17 (controllable-by-others) “resources available” loaded the highest on the second factor. Perhaps the wording of the item was unclear, so that the majority of participants related it to themselves rather than to other resources. Item 9 (centrality) “will be affected” loaded the highest on factor 1, which indicates that the importance of a potentially challenging situation is closely related to the experience of stress. The same applies to two items on the “threat” scale; which also loaded the highest on the first factor. Item 19 (challenge) had the highest load on the first factor, “overall perceived stressfulness”. Since excitement goes hand in hand with the feeling of stress, this high charge is understandable. Overall, however, the various assessments and the general experience of stress could be well mapped separately from one another by the scenario, which suggests that the content of the questionnaire with its subscales is well applicable. Although the results do not speak for a relative independence of the individual subscales in all cases, a variance of R = .48 could be explained in the hierarchical regression with all six subscales. Similar to the results of previous studies, the predictors “threat” and “centrality” were the relevant predictors for experiencing stress [25,26,31]. The appraisal of “controllable-by-self” had a negative effect on the experience of stress, at least in the marginally significant range.

The described situation in the short story was seen as challenging by the participants (mean: 2.97). Furthermore, this was perceived as not particularly threatening (mean: 1.47). The information matches the responses of the participants on the perception of their own psychological and physical stress when treating children and adolescents with ASD. The results of the present study, which the SAM provides as an evaluation tool, can thus confirm for the first time the assumption that a dental examination of children and adolescents with ASD by dentists is a challenge. It was already shown in other studies (e.g. on birth) that the SAM can validly map sensations. A Portuguese study described that expectant parents perceive the birth of a child mainly as a challenge and only rarely as a threat [31]. One reason why a situation is perceived more as challenging and less as threatening could be that the interviewed person is able to cope with the situation in a problem-oriented manner, e.g. by making plans to solve the stressful experience and thus accept the challenge. Emotion-oriented coping, on the other hand, rather includes the regulation of the negative emotions caused by the situation and is related to the perception of the threat of the situation and the experience of stress [26]. The missing correlations in our study between “threat” and “challenge” make it clear that these perceptions are not related to one another. In a focus group, dentists and the dental team reported that it makes sense and is an investment in the future to take time for these patients. According to the study, the experience with dental treatments of persons with ASD can be improved by good preparation for the appointments and by education about ASD [49]. Five overarching issues are identified by dentists as the challenges in treating patients with ASD: 1.) each patient with ASD has their own needs, 2.) communication plays a key role, 3.) specific techniques for ASD are important, 4.) a conflict between needs and ressources and finally 5.) the personal reward for the work [50].

The study

As a limitation of the present study, it should be mentioned that this study was only carried out among members of DGKiZ which represents only one out of several dental associations for German dentists. Mainly, persons with key interest and key expertise in paediatric dentistry join this association. These dentists are generally very experienced in dealing with children and adolescents, including children with underlying diseases. It is very pleasant for the author team that the group of German dentists with key expertise in paediatric dentistry confirm the expected result of good stress resistance in dental care of children and adolescents with ASD. If validation had not been successful in this group, further validation in larger and other groups of dentists from Germany would probably not have been necessary. Now, in order to continue the process of validating the SAM in dentistry and to broaden the topic overall, a survey has already been carried out for German dentists from the public health service. A survey including the SAM for general German dentists is being planned. Moreover surveys about the dental care situation have also already been carried out, with the concerned parents and caregivers of e.g. persons with ASD. In addition, primary data collection on dental care and prevention in children, adolescents and younger adults with neurodevelopmental or intellectual disabilities (in particular with ASD) in Germany is planned. Furthermore, it should be discussed whether these planned surveys should be carried out online-based or in paper-pencil style, since a response rate of the participating members of 5.3% percent with a fully completed questionnaire can be viewed as below average. We only recruited the participants online. More than 190 persons started to complete the online questionnaire. Due to a high number of missing values, many participants could not be included in this analysis. Therefore, the SAM results of the present study cannot be regarded as representative for all German dentists but it offers an insight into important topics in relation to special needs dentistry in Germany that have not yet been examined. In order to obtain a higher participation rate for further projects it might be useful to recruit participants not only via e-mail but also at conferences.

Conclusion

Cognition and processing of stress can be measured feasibly and with sufficient validity using "Stress Appraisal Measure" (SAM) also in dentists. The underlying model of stress response is reconfirmed for SAM. Factor analyses and the SAM analysis reveal that dental diagnostic procedures in children and adolescents with ASD are perceived more as challenging than as threatening situation by German dentists with key expertise in paediatric dentistry. Therefore, special training sessions in special needs dentistry are recommended for all dentists who are involved in the treatment of children and adolescents with ASD.

9 Mar 2022

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We look forward to receiving your revised manuscript.

Kind regards,

Andrej M Kielbassa, Prof. Dr. med. dent. Dr. h. c.

Academic Editor

PLOS ONE

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“The authors declare that the study was funded by the Department of Special Care Dentistry at Witten/Herdecke University and the Department of Child and Adolescent Psychiatry, Psychotherapy and Neurology of Childhood and Adolescence at the Gemeinschaftskrankenhaus

Herdecke as part of a collaborative project between the two departments. This scientific project is financially supported by the Software-AG-Foundation based in Darmstadt/Hesse, Germany.”

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Abstract

- "(...) sent to members of the German Society of Paediatric Dentistry (DGKiZ) via a link to participate." Please add number of members having been invited to participate.

- "92 participants (11 male, 81 female) fully completed the questionnaire." Must read "Ninety-two participants (...)", please re-edit. Indeed, 92 would seem a poor number only. Why do you think that this would result in some kind of representative outcome?

- "(...) and in some cases there were high intercorrelations between the scales, (...)." Please provide exact results, give r and p values. Phrases like "some cases" or "high intercorrelations" would not seem acceptable. Please remember that future readers will decide switching to your full text AFTER having read your Abstract section.

- "This could be reasoned in the circumstance that the participants in the present study were generally very experienced in treating children, including children e.g. with underlying diseases." This would not seem astonishing. Do you see any news from your study, not only confirmative ones?

- "In future, dentists who rarely treat children could also be surveyed in a further, larger study." Do not stick to meaningless phrases here. With your Conclusions, please stick exclusively to your revised aims (see comments given below). Do not simply repeat your results (or even speculate) here. Instead, provide a reasonable and generalizable extension of your outcome.

Intro

- This study has been finished, right? "The purpose of the present study is to check (...)" must read "The purpose of the present study was to check (...)".

- Same with "(...) is examined."

- Both aims and objectives elaborated here would seem convincing. However, "SAM’s utility" aspects should be mentioned with your Abstract section, too. Please revise/adapt carefully.

Meths

- Do not use legal terms like GmbH, ®, and so on.

- With ALL materials and methodologies (including statistical software), please use general names with your text, followed by (brand name; manufacturer, city, ST [if US], country) in parentheses. Stick to semicolon. Revise thoroughly.

- "Before the start of the study, a positive vote for carrying out the survey was obtained from the board of the DGKiZ." What about the positive vote of an Ethical Committee? Please provide vote number and date of approval.

- "Since the data collection was planned in accordance with the European General Data Protection Regulation and represents an expert survey, a formal ethics application to the responsible ethics committee of the Witten/Herdecke University was not performed before the start of the project." This would seem astonishing. An "expert survey" does not need an ethical approval? Please provide a sound and reliable reference.

- "(...) successfully sent to 1.725 e-mail addresses (...)." Please see comments given above. With 92 respondents, some 5% have participated only, and this would not seem a reliable database, don't you think so?

- "(...) This measures cognitive processing mechanisms and perceived stressfulness in the event of acute stress [26]. Peacock and Wong see the transactional stress model as the basis of their questionnaire [34,35]. According to this model, stress arises from (...)." This does not seem to refer to your methodology, but might be discussed later. Please revise carefully, and focus on the methodology here.

- Reduce repeated mentioning of Author names, please (see, for example, "Peacock and Wong", but this also refers to other names). Instead, please focus on your main thoughts, to ensure readability (Authos' previous work will be acknowledged with your References section).

- Legend Fig 1: Please do not repeat the full reference here, see comments given above. [Number] will be sufficient.

- Same with legend of Table 2 and Table 4.

Results

- Revise carefully for any typos. See, for example, Table 1, "(e.g. students. persioner)".

- "The Kaiser-Meyer-Olkin coefficient as a measure of sample suitability was .80. Since this value was above the lower limit of .50, a factor analysis could be carried out [37]." Please provide more information on the "suitability". Again, see comments given above, and remember that 92 respondents would not seem convincing.

- Please double check, and revise for correct inter punctuation. See "(β = .64. R2 = .41 p <.01)".

- Again, several aspects should be explained and discussed in the Discussion section. Here, please focus on the results.

Disc

- "To our best knowledge, there is no study that specifically deals with the psychological and physical stress on dentists from Germany when treating children and adolescents with ASD." It would seem unclear why "dentistry from Germany" have been considered important for the Authors. What would predispose "German dentists" from other nations? What about the transferability of your outcome to other dentists from other countries?

- "This study now offers this information for the first time." And now? Again, why do you think that his would be important?

- Again, please revise for minor shortcomings, see "Since the majority of our study participants already had of professional experience of (...)."

Concl

- Remember that this section is not a second summary. Again, with your Conclusions, please stick exclusively to your revised aims. Do not simply repeat your results (or even speculate) here. Instead, provide a reasonable and generalizable extension of your outcome, which must be based on your results.

- The current version of this section would seem right, but major aspects must be provided with the Discussion section, since these are not considered conclusions from your study.

Refs

- Please stick to the Journal guidelines, and consults some recently published Plos One papers.

- Style would be "Tanagawa M, Yoshida K, Matsumoto S, Yamada T, Atsuta M. Inhibitory effect of antibacterial resin composite against Streptococcus mutans. Caries Res. 1999; 33(5): 366–371. https://doi.org/10.1159/ 000016535 PMID: 10460960" Revise thoroughly.

In total, this submitted draft would seem interesting, is considered easily intelligible, and should be worth following after a thorough revision, following the aspects given above. Additionally, the manuscript is ready for external review.

Reviewer #2: Many thanks for asking me to review this paper.

Overall summary

While I acknowledge there is little data available on this topic in Germany, overall I do not feel this paper merits publication in a prestigious journal like PLOS ONE. The questionnaire response rate of 5% is inadequate and liable to survey error and a high degree of reporting bias.

It may have been more prudent for the investigators to find new ways of engaging with the survey population to yield an improved response rate to the survey, rather than attempt to publish a questionnaire survey with such a poor response rate. As almost 95% of the survey population did not respond, I do not feel any credible conclusions can be drawn on the views of German paediatric dentists towards treating children and adolescents with autism spectrum disorders.

I have some further more specific comments to share below that may help to improve the paper, should attempts be made to improve its methodological rigour:

The title of the paper could be revised to represent the fact that it is a questionnaire study and restricted to paediatric dentists.

The paper is difficult to follow and would benefit from a technical restructure to provide a clearer rationale for the research question, clearer explanation of background context and greater clarity over terms used to define the population of interest and why this particular methodology was chosen. There may be more appropriate methodologies for investigating this topic and it doesn’t feel like this approach has elucidated the views of German paediatric dentists in a complete and comprehensive way. The methodology appears overly complex for such predictable results, which leads me to think why this research was necessary.

I fully appreciate the authors are using a second language, but in places it is not clear what is meant, in particular in the background are references being made specifically in regard to autism spectrum disorders or disability/mental disorders more generally?

In terms of the methods there are insufficient details of the questionnaire development (piloting and refinement of the tool), administration (for example how were duplicate entries managed, or ineligible individuals accounted for), anonymity, storage and management of the data, and there is no reference to efforts to maximise the response rate. A recruitment diagram would aid reader understanding of the process and response and completion rates. Particularly as the response rate is only referred to in the conclusion section. In addition, a copy of the questionnaire should be provided as an online appendix to accompany the paper.

The rigour of the results and corresponding conclusions can only be appraised based on a more robust response rate, which is not observed in this work.

Reviewer #3: Summary

The manuscript is well written and particularly scientifically sound as the results of the study are given in elaborate detail. The data analysis is very extensive and the regression analysis is discussed in great depth. The study clearly highlights the novel element of using the SAM as a survey tool for measuring stress perceptions and stress appraisal.

Minor Revision

However there are few points that still need further elaboration:

1. It would be helpful for the reader if the authors added a few lines explaining the terms used for the seven subscales (threat, centrality, controllable-by-self, controllable-by-others, uncontrollable, challenge and stressfulness) and what they denote in light of the study.

2. There is a very detailed representation of data in Table 1 regarding the demographic aspects of the study but no mention of these results in the discussion. It would be interesting to see how age, gender and the working arrangement of the dentists relate to the psychological and physical stress experienced by them when treating children with ASD. There is a clear majority of females in the study and its relation to the results must be highlighted in the discussion.

3. More references of studies done in other parts of the world can strengthen the discussion especially those studies where dentists having less experience are questioned for the study.

4. Line 65, the word should be ‘based’

5. Line 113, what is the meaning of ‘resp’ or is it a typo?

6. Line 338, a in place ‘of’

7. Line 393, ‘states’ instead of ‘statements’.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Dr Fatima Suhaib

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22 Apr 2022

We respond to specific reviewer and editor comments in the "answers to the reviewer"

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

26 May 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Andrej M Kielbassa

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: With the help of the reviewers, this revised and re-submitted draft has been considerably improved, and is considered ready for external review.

Reviewer #2: (No Response)

Reviewer #3: While the authors have made some improvemnets in the article however I still feel that there should be mention of similar studies done in other parts of the world as it gives a bigger picture of the challenges faced in dealing with children with Autism.

If the the authors can highlight this point then it is acceptable for publication.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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23 Jun 2022

Dear Professor Kielbassa, dear reviewers,

we would like to thank you for the helpful notes and comments on our submitted manuscript. We hope that we were able to meet the editorial requirements of the journal as well as the needs of the reviewers to improve the manuscript in our revision.

Comments from external reviewer:

While I acknowledge the authors have made significant attempts to address my points and there are improvements to the manuscript, I am still of the opinion that the study lacks meaningful results due to coverage issues which have limited impact.

Thank you very much for your review. Thank you for acknowledging our efforts to improve the manuscript based on your comments. With regard to the sample size and the generalization of the results to the population of German dentists with key interest and key expertise in paediatric dentistry or to general dentists, the impact of the results can certainly be regarded as limited. However since the question of stress vs. challenge has not yet been scientifically investigated, but has always been spoken of as a challenge based on experience, we assume that our manuscript has a scientific impact.

In lines 441 to 451 we address the fact that further research work of our scientific group will advance the validation process of the SAM in dentistry. Furthermore, we are working on the topic of examination of patients with ASD in dentistry in further surveys (441-451, page 22).

The results of the feasibility of the SAM are meaningful in our opinion, as they confirm similar results from other studies on the feasibility with a different sample. Cognition and processing of stress can be measured feasibly and with sufficient validity using the "Stress Appraisal Measure" (SAM) also in dentists.

Finally, we would like to point out that in the few studies on the subject of "attitudes of dentists to the treatment of children with ASD" also small sample sizes were reported. For example the study by Weil et al 2010 „Treating patients with autism spectrum disorder -SCDA members' attitudes and behavior“ only reported a sample size of 75 members of the society .

Although the response rate to the survey is mentioned more explicitly as a key limitation in the study, and it is now mentioned appropriately in the abstract, reference to it is still missing from the results section. An overall response rate should be presented in the first line of the results section to ensure readers understand the context to the results and how many respondents they relate to, this is a key expectation in cross sectional studies. I am aware that many journals will not publish a cross sectional survey with such a low response rate and I am not convinced the authors responses adequately address the issue of quality in their approach.

We presented the overall response rate (for the fully completed questionnaires and for all questionnaires started) in the first line of the results section (219-221, page 10).

The results of the study are not particularly remarkable, as one would expect dentists with an interest in paediatric dentistry to experience less stress when treating children and adolescents with ASD. Again, this for me is a design flaw and the study might have applied an alternative design to elucidate the views of different type of dentists, which might of provided some greater insight into the issue. Indeed, the conclusion of the paper appears to recommend “special training sessions in special needs dentistry for dentists involved in the treatment of children and adolescents with ASD” but I am not sure the results of this study substantiate this point and it is not clear if the paper is recommending more training for paediatric dentists or the general dental population. I suspect it is the latter but that cannot be made based on the results of this study. This study provides only data on the utility of SAM in measuring stress response and the perceived levels of stress in a small sample of pediatric dentists.

For incremental validation, we started with a small group of dentists (those with expertise in paediatric dentistry). If validation had not been successful in this group, further validation in larger and other groups of dentists from Germany would probably not have been necessary.

Now, our scientific working group is planning further surveys on this subject and same questions with general dentists and has already carried out surveys with dentists in the public health sector and also with people working in child and adolescent psychiatry, psychosomatic medicine and psychotherapy in Germany.

Our assumption is that general dentists experience a higher level of stress when treating children and adolescents with ASD than dentists with key expertise in paediatric dentistry. This must now be checked in one of the next steps. Nevertheless, we recommend, in the knowledge from the professional (clinic and research everyday life), that further training on this topic are recommended for both groups (general dentists and dentist with key expertise in paediatric dentistry) or for all dentists.

6. Review Comments to the Author

Reviewer #1: With the help of the reviewers, this revised and re-submitted draft has been considerably improved, and is considered ready for external review.

Thank you very much for your review.

Reviewer #2: (No Response)

Reviewer #3: While the authors have made some improvements in the article however I still feel that there should be mention of similar studies done in other parts of the world as it gives a bigger picture of the challenges faced in dealing with children with Autism. If the the authors can highlight this point then it is acceptable for publication.

Thank you very much for your review. We researched further studies on the topic and included them in the manuscript.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

30 Jun 2022

Is examining children and adolescents with autism spectrum disorders a challenge? - Measurement of Stress Appraisal (SAM) in German dentists with key expertise in paediatric dentistry

PONE-D-21-39587R2

Dear Dr. Reis,

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Prof. Dr. med. dent. Dr. h. c. Andrej M. Kielbassa

Academic Editor

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26 Jul 2022

PONE-D-21-39587R2

Is examining children and adolescents with autism spectrum disorders a challenge? - Measurement of Stress Appraisal (SAM) in German dentists with key expertise in paediatric dentistry

Dear Dr. Reis:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Prof. Dr. med. dent. Dr. h. c. Andrej M Kielbassa

Academic Editor

PLOS ONE