Assessing children’s dental anxiety:
A systematic review of current measures
1Porritt,
J. , 2Buchanan, H., 1Hall, M., 1Gilchrist, F. & 1Marshman, Z.
Running head: A systematic review of children's dental anxiety measures
1
Academic Unit of Oral Health and Development
School of Clinical Dentistry
University of Sheffield
Claremont Crescent
S10 2TA
2 Institute
of Work, Health & Organisations
International House
Jubilee Campus
Wollaton Rd
Nottingham
NG8 1BB
1
Abstract
Objectives: The reliable assessment of children’s dental anxiety can have many
benefits for the dental team, service providers and dental public health practitioners.
This study aimed to identify and evaluate self-report measures which are available to
assess children’s dental anxiety.
Methods: Systematic searches of the literature between 1998 and 2011 were
conducted to identify relevant studies. The properties of each measure (reliability and
validity) were assessed and measures were evaluated against a theoretical framework
of dental anxiety.
Results: Executing the search strategy generated 498 articles and of these 60 studies
met all of the inclusion criteria. Seven ‘trait’ and two ‘state’ measures of dental anxiety
had been employed to assess children’s dental anxiety over the past decade.
Reliability and validity estimates for the most widely used measures were good,
however, many questionnaires had a limited focus in the aspects of anxiety they
assessed.
Conclusions: The paper summarises the measures of children’s dental anxiety which
may be most useful for a number of different purposes and populations.
2
Introduction
Dental anxiety is a common problem which develops mostly in childhood and
adolescence [1, 2].
Approximately half of children report low to moderate dental
anxiety and between 10% and 20% report high levels of dental anxiety [3, 4]. It should
be recognised that the nature of a child’s dental anxiety can vary significantly and
whilst some children present with fears or phobias in relation to specific dental stimuli
(e.g. needle or drill) [3, 5-7] other children report more generalised anxiety associated
with the dental setting [8].
In practice differentiating dental anxiety, fear and phobia is complicated and these
terms are often used interchangeably within the literature [9]. Classified under the
umbrella of anxiety disorders, a phobia is a clinical diagnosis and refers to a marked
fear which interferes with a person’s normal routine, whereas fear is not always
extreme [9]. However, the term dental anxiety is often used to include all different
types of dental fears and phobias.
Dental anxiety can have major implications for the child, dental team and dental
services. Children with high levels of dental anxiety have increased numbers of
decayed, missing and filled tooth surfaces compared with children who have low levels
of dental anxiety [5, 10-13]. Providing treatment for a dentally anxious patient can be
time consuming, costly and demanding for the clinician [14, 15]. These factors may
result in children being referred to secondary dental care services and having to wait
longer periods of time for their dental treatment. Indeed, anxious children are one of
the key groups that are seen by specialist services [16-18].
3
The way in which dental anxiety develops has received much of the attention within
the dental anxiety literature, however, it is also important to understand how children’s
anxiety is being maintained over time as symptoms of anxiety can intensify into
adulthood [19-21]. It is recognised that dental anxiety can be maintained through a
cycle whereby bodily arousal, cognitive interpretation and ineffective behavioural
coping strategies work in a feedback loop [22]. The Five Areas Model of anxiety [23] is
a theoretical framework based on a cognitive behavioural model, which outlines how
an individual’s i) thoughts ii) feelings iii) behaviours iv) physical symptoms and v)
situation are all inter-related and can contribute to increased feelings of anxiety. Using
this model the appropriate psychological treatment can be identified and aspects of the
child’s anxiety which are maintaining their fear (e.g. unhelpful thoughts, unhelpful
behaviours) targeted.
On consideration of the evidence which links dental anxiety with poor oral health
outcomes it is important that children with dental anxiety are identified from an early
stage and that the prevalence of dental anxiety, and its impact in a population, is
established and monitored. Three broad methods of assessing children’s dental
anxiety include: i) direct observation of the child’s physiological state or behavioural
response in the dental context (usually by either dental personnel and/or researchers)
ii) the completion of a questionnaire by the parent as a proxy measure of how anxious
the child is and iii) self-report scales completed by the child [24]. Using clinical
observations alone is not reliable with studies showing that there is poor to moderate
agreement when dentists’ ratings are compared to the child’s own anxiety ratings [25,
26]. Whilst children with dental anxiety may be more likely to exhibit negative
emotional and behavioural reactions within the dental encounter [27, 28], some
children do not display overt presentations of anxiety and behavioural reactions
sometimes interpreted as manifestations of anxiety can be due to other factors, such
4
as behavioural management problems. Moreover, physiological responses have been
questioned in terms of validity [29] and some forms of physiological measurement
(such as cortisol) can be costly to analyse and are not appropriate for routine anxiety
assessment in clinical practice. Proxy measures also have limitations. It has been
proposed that parents often reflect their own anxiety, rather than reflecting the views of
their children [30]. Previous research has revealed that parents are not able to reliably
assess children’s levels of dental anxiety [31] with studies showing only moderate
agreement between child and parental ratings [32, 33].
Overall, self-report measures of dental anxiety completed by the child themselves
(where this is feasible) are the most reliable and valid method of assessing anxiety
with many benefits for the dental team, service providers and dental public health
practitioners (Table 1). For example, dental anxiety measures can be used for a
variety of purposes including determining population prevalence of dental anxiety,
measuring risk factors and symptoms in individuals and assessing changes in anxiety
over time (e.g. pre-post treatment interventions) [9].
Research has revealed that children aged eight-years-old and over can reliably report
on virtually all aspects of their health [34]. Whilst children as young as three and four
can effectively communicate emotional and physical experiences such as pain there
are clear developmental differences in children’s abilities to understand and report on
their emotional and cognitive states [35, 36]. Therefore, for children to be able to
accurately complete self-report items measures must demonstrate developmental
validity [37], which means that children should be able to comprehend the questions
and response alternatives included within the measure. The child’s comprehension will
be dependent on the complexity of the language and specific terminology used within
the measure. For example, there is some evidence that the word ‘worried’ is
5
understood by more children, aged between five and seven years old, than the term
‘nervous’ [34]. Therefore, the way it which the current dental anxiety measures have
been developed/modified and tested with children of different age ranges and
capabilities is an important area of evaluation.
Rationale
Up-to-date information on the properties of the different self-report measures should
be made available if assessments of children’s dental anxiety are to be encouraged. It
has been proposed that researchers interested in dental anxiety should also be aware
of the dimensions of anxiety which are assessed by the different measures available
[38]. Therefore, it is important to understand the way in which the construct of anxiety
is operationalised within the different measures when choosing the most appropriate
self-report dental anxiety measure to use [39]. For example, if the purpose of
assessment is to inform clinical treatment planning, it may be important to assess the
multidimensional nature of the patient’s dental anxiety and examine factors which are
contributing the maintenance of their anxiety. In contrast if the main objective is to
collect information relating to the prevalence of dental anxiety in a particular group or
community then a reliable and valid measure which has established cut-off points may
be the priority. Ultimately, the recommended dental anxiety measure of choice will be
determined by the type of information the researcher, health care professional or
epidemiologist would like to obtain from the assessment.
Previous reviews which have evaluated self-report measures of dental anxiety were
published over ten years ago [38, 40] and since this time, new measures of dental
anxiety have been developed. Klinberg recently highlighted the need for paediatric
dentists to carry out assessments of children’s dental anxiety and provided an
overview of the different methods available [41]. However, Schuurs and Hoogstraten,
6
in their review of adult dental anxiety measures, highlighted the importance of
evaluating, in detail, the aspects of dental anxiety which the different measures assess
[39]. Therefore, the aim of this systematic review was to identify and evaluate selfreport measures of dental anxiety which have been used to assess children’s dental
anxiety since the date of the last systematic review in this area. Specific objectives
included: i) providing a descriptive account of each measure (e.g. number of items,
scoring); ii) providing information relating to the validity and reliability of each measure;
iii) providing information about the way in which these measures had been developed
(e.g. level of child involvement); iv) evaluating which aspects of dental anxiety they
assess and v) describing the study populations in which the different measures have
been employed (e.g. age ranges, countries). The findings of this review will help inform
the choice of such measures for dental practitioners, service providers and
epidemiologists.
Materials and Methods
Design and search strategy
Titles and abstracts of all studies published between July 1998 and August 2010 using
Medline (via Pubmed) and 1998 – 2010 using Social Science Index Citation (via Web
of Science) were searched. The search terms used included child related keywords
(child* OR young OR young person OR minor* OR paediatric* OR pediatric*) AND
dental anxiety related key words (dental anx* OR dental fear* OR dental phobia* OR
odontophobia*). In order to be included within the review, studies had to have
employed measures of dental anxiety completed by children themselves (≤16 years),
been published in English and reported primary data. Studies which used proxy
measures of children’s dental anxiety were excluded. Single-item measures of dental
7
anxiety which had not been validated (no established reliability or validity estimates
available) and anxiety measures which were not dental-specific were also excluded.
A preliminary screening of the abstracts and titles, revealed by the search, enabled the
identification of potentially relevant studies. The reviewing team consisted of
professionals from a variety of disciplines (paediatric dentistry, health psychology,
dental public health and medical sociology). Pairs of trained reviewers from the team
independently applied the inclusion criteria when reviewing the abstracts and complete
papers. All papers that passed the abstract screening were retrieved in their complete
forms and data extraction was conducted. A standardised data extraction form
informed by previous reviews [39, 42] was developed, piloted and employed by the
three pairs of independent reviewers. There was ≥85% agreement between reviewers
for study inclusion when abstracts were reviewed and ≥90% agreement for study
inclusion when complete papers were reviewed. Disagreements were successfully
resolved through discussion.
The original validation papers, for all of the measures identified within the review, were
also consulted. The reliability and validity estimates and means reported in these
original research papers were included in the results unless the measures had been
validated with adult participants.
8
Data collection
Data were extracted from the original articles, which described the development of the
self-report dental anxiety measures, and all of the studies which met the inclusion
criteria. Information related to the settings in which the different measures had been
employed (e.g. clinical and population) was collected. The mean scores and reports of
validity and reliability for each measure were also collected from these studies.
The validity of a questionnaire was typically assessed by examining how well the
measures correlated with a previously validated measure which assessed the same
construct (concurrent validity). Information relating to whether measures had been
developed/tested with children was also examined to evaluate the developmental
validity of the measures. The reliability of a questionnaire was assessed by examining
the internal consistency of the items included (e.g. Cronbach’s alpha) and the stability
of the questionnaire, when assessing a particular construct over time (e.g. test-retest
reliability). Information related to other aspects of each measure was also collected
which included: questionnaire length; response format; scoring method; and
established cut-off points. Details regarding the specific aspects of dental anxiety the
measures assess, as conceptualised by the Five Areas Model of anxiety [23] (e.g.
thoughts, feelings, behaviours, physical symptoms, situational triggers), were also
examined and reported.
Results
Executing the search strategy generated 498 articles. Following the reviewers’
assessments of the abstracts, a total of 68 papers were identified as duplicates and
9
250 did not meet the sample criteria. Of the 180 abstracts which passed the abstract
screening, 179 were reviewed and one paper could not be obtained by the research
team. After obtaining the full papers a further 119 papers were excluded leaving a total
of 60 papers which met all of the study’s inclusion criteria (Figure 1).
Nine self-report measures of dental anxiety were employed within these studies.
Summary and key points for the nine measures are described in Table 2. Information
on the measures’ reliability, validity and areas assessed (e.g. thoughts, behaviours,
physical symptoms, feelings and situational triggers) are also presented in Table 3.
Means and reliability/validity estimates reported in studies which used modified
versions of measures (e.g. reduced number of items or altered scoring procedures)
were not reported.
Unless indicated otherwise, the scales described below are ‘trait’ measures. Generally
‘state’ measures can only be employed in the dental context (e.g. in the dental waiting
room/in the dental chair) as they are purporting to measure how the child feels at that
moment in time whereas ‘trait’ measures can be employed out of the dental context
and assess the child’s dental anxiety across a variety of dental contexts or procedures.
The Children’s Fear Survey Schedule Dental Subscale (CFSS- DS) [43]
The CFSS-DS measure was the most popular measure of dental anxiety used to
assess children’s dental anxiety, employed in 28 studies. This self-report measure was
developed from the Fear Survey Schedule for Children, a 80 item questionnaire
designed to assess a variety of children’s fears and anxieties [44]. The CFSS-DS is a
dental specific measure which requires children to rate how frightened they are in
response to 15 dental-related situations/treatments (e.g. ‘dentists’, ‘injections’ and
‘having somebody examine your mouth’). The CFSS-DS was found to have high
10
reliability and established cut-off points. The measure has also been used with a wide
age range of children. However, the measure does not assess the physical reactions,
thoughts and behaviours which may contribute to children’s dental anxiety. It should
also be noted that some of the specific situations assessed within the measure are not
highly relevant to dental anxiety (e.g. ‘doctors’). Whilst the measure was developed for
children there is no evidence (from examination of the original article describing the
development of this questionnaire) that children were involved in the development of
this measure. It should also be noted that a number of studies which have used this
measure have dropped several of the original items to create a shorter version of the
questionnaire, making data comparability difficult [5, 7, 45].
Dental Fear Schedule Subscale Short Form (DFSS-SF) [46]
The DFSS-SF was used in seven studies. The measure is a shorter version of the
CFSS-DS measure containing eight items and asks children to rate how frightened
they would feel in response to eight specific dental-related situations/treatments. The
measure shares some of the advantages of the CFSS-DS and the reduced number of
items means that the measure has the added advantage of being quicker to complete
than the CFSS-DS. Another advantage of the DFSS-SF is that items which are not
highly relevant to dentistry (e.g. ‘doctors’) have been removed from this shortened
questionnaire. However, the measure shares a number of the drawbacks of the CFSSDS, which have previously been described.
Dental Anxiety Scale (DAS) and Modified DAS [47]
The DAS was used in thirteen studies and one study employed the Modified DAS [24].
The DAS is a four-item measure and the MDAS a five item measure, both were
developed to assess dental anxiety in adults. Participants indicate how relaxed or
anxious they feel about four dentally related situations (e.g. ‘If you had to go to the
11
dentist tomorrow for a check-up, how would you feel about it?’) by choosing from a
series of responses (e.g. ‘relaxed’, ‘I would look forward to it as a reasonably
enjoyable experience’). This measure explores the situational triggers of dental anxiety
and physical reactions experienced by dentally anxious individuals. Pictorial response
formats have also been used with the DAS [4, 13]. For example, the Facial Image
Scale [48] has been combined with the DAS to produce the combined dental anxiety
scale (COM-DAS) [4]. Whilst studies employing these measures have reported high
reliability estimates, these measures were developed to assess adult’s dental anxiety
so the instructions, items and response format may not be appropriate for children. No
validity estimates were available for the measure when employed with child
participants and the measure does not assess the unhelpful thoughts or behaviours
which may be contributing to the child’s dental anxiety
Modified child dental anxiety scale (MCDAS) [49]
The MCDAS [47] was used in ten studies and contains eight questions, four of which
are based on the original DAS. The additional anxiety-provoking dental situations
assessed by the MCDAS include dental injections, general anaesthesia, extraction
and sedation. Children were involved in developing a child appropriate response
format for the MCDAS. The measure assesses the child’s general level of dental
anxiety and seven possible situational triggers of dental anxiety. Reliability and validity
estimates suggest that internal reliability is high and the measure is able to
discriminate between children with and without dental anxiety [50]. There is also a
faces version of the MCDAS (MCDASf) [50] which incorporates faces (similar to the
Facial Image Scale but the final face on this scale is crying) within the response
format. The faces version of the measure was developed to be more suitable for
children as young as three years old and those with limited cognitive functioning [50].
However, the MCDAS does not assess unhelpful thoughts, behaviours or physical
12
reactions which may be contributing to children’s dental anxiety and the two questions
it contains on sedation/anaesthesia may limit its possibilities in situations where the
child is unfamiliar with these procedures.
Facial Image Scale (FIS) [48]
The FIS comprises one item with a response set of five faces (ranging from a very sad
to a very smiley face). Children are asked to indicate which of the faces they feel most
like at that moment; thus it is a ‘state’ measure of anxiety. The FIS has been used as a
standalone measure [48, 51-53] and as response set for the MCDAS and CDAS
measures [4, 54, 55]. The FIS was developed to allow for limited cognitive and
linguistic skills of younger children [48] and provides an immediate reflection of how
the child is feeling, which may be useful for clinicians. However, when assessing the
face validity of the measure it could be argued that the item may assess the child’s
mood at that point in time, rather than their ‘state’ dental anxiety. The measure also
does not assess specific triggers of dental anxiety or potential unhelpful thoughts,
behavioural or physical reactions which may be contributing to the child’s anxiety. No
reliability estimates are available for this measure, (as it is a one ‘item’ state measure),
however, the measure has been found to be significantly correlated with the Venham
Picture Scale indicating concurrent validity [56].
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Venham Picture Scale (VPS) [56]
The VPS is a pictorial measure of dental anxiety which was employed in four of the
included studies. This ‘state’ measure incorporates eight pictures with each depicting
two cartoon boys displaying contrasting emotions. The participant is required to
indicate which of the boys, within the eight pictures, most accurately reflect their
feelings at that time. The measure was developed to be suitable for children as young
as three so the use of pictures alleviates the need for children to possess developed
language skills, with children being able to respond to the measure nonverbally. One
of the main disadvantages of the measure is that some of the emotions displayed in
the eight pictures are ambiguous (i.e. it is unclear what behaviour/feelings they are
displaying) [48]. This ‘state’ measure does not explore possible situational triggers of
dental anxiety nor does it have established cut-off points to help administrators of the
questionnaire distinguish between anxious and non-anxious children. Internal
consistency of the pictures is high, however, there is no information relating to the
validity of the measure.
Dental Fear Survey (DFS, 20-item version) [57] and modified version of the DFS [58]
The Dental Fear Survey was originally a 27-item questionnaire developed to assess
dental anxiety in adults [59] and was later revised to a 20-item measure of dental
anxiety [57]. The revised 20 item measure was used in two of the reviewed studies
and a further modified 15 item questionnaire [58] has also been used to assess
children’s responses to a variety of dental situations (e.g. ‘sight of injection’ and
‘feeling the drill’) and general fear of dentistry. The 20 item DFS had excellent internal
consistency when used with children aged between eight and eighteen. However,
some of the situational triggers may not be relevant to children (e.g. ‘making a dental
appointment’). Whilst the questionnaire does not assess unhelpful thoughts children
14
may experience it does assess a variety of unhelpful behaviours (e.g. ‘failed to appear
for a dental appointment’) and physical reactions (e.g. ‘muscle tenseness’) which may
be contributing to children’s dental anxiety.
Smiley Faces Programme (SFP) and Revised SFP [60, 61]
Two validation studies report on the properties of the SFP and SFP-R, which are fully
computerised measures incorporating items derived from the Modified Dental Anxiety
Scale [62]. The measures include a seven item facial image scale as an interactive
response format. The original SFP measure requires children to indicate how they
would feel in response to four dental scenarios (e.g. ‘Having to have dental treatment
the following day’) and the Revised SFP includes an additional dental scenario (‘about
to have a tooth out’). Both the SFP and Revised SFP were piloted with children and
revisions were made to the measures based on children’s suggestions and
experiences. The interactive nature of the measure could appeal to both child
patients/participants and researchers. However, the use of this measure relies on
computer access and unhelpful behaviours, thoughts and physical reactions, which
may be contributing to the child’s anxiety, are not assessed.
Short version of the Dental Anxiety Inventory (S-DAI) [63].
The S-DAI was employed by only one of the studies included within the review. The
measure includes nine items and requires respondents to indicate their level of
agreement with a number of dental related statements (e.g. ‘When I know the dentist
is going to extract a tooth I am already afraid in the waiting room’ and ‘As soon as the
dentist gets his/her needle ready for the anaesthetic, I shut my eyes tight’). One of the
main advantages of the measure is that it takes into account different situations and
treatments which may trigger dental anxiety, whilst assessing physical reactions,
thoughts and behavioural aspects of dental anxiety experienced by the individual.
15
However, the questionnaire was developed as an adult measure of dental anxiety and
so it is proposed that the lengthy scenarios described and response format may not be
suitable for (younger) children. No reliability and validity estimates were available for
the measure when employed with child participants.
Discussion
The review revealed nine self-report measures of dental anxiety had been employed to
assess children’s dental anxiety over the past decade. The previous review conducted
in 1998 identified only three self-report measures of children’s dental anxiety [38] and,
therefore, there has been a larger pool of scales available for researchers and
clinicians to choose from in recent years. Anxiety can be measured for a number of
different purposes and populations (as highlighted in Table 1) and as such a ‘one size
fits all’ measure is not always appropriate. Below, we summarise which measures may
be most useful for clinical, service organisation, survey or research purposes.
At a patient level, a trait measure administered at a new patient appointment may help
identify patients with high levels of anxiety and/or specific dental fears. Practitioners
may consider using the findings for treatment planning and as a communication tool.
The desirable properties of a measure to assess dental anxiety in this setting would be
i) short, to allow it to be completed in the waiting room; ii) suitable for a wide range of
ages; iii) contains a variety of questions related to specific dental procedures, and iv)
developed with children to ensure that response formats are clear and that the items
used are valid. Therefore, measures such as MCDAS/MCDASf and SFP (though a
computer would be required for this measure) may be particularly useful in this setting.
The Dental Fear Survey [57] assesses multiple aspects of the child’s anxiety (e.g.
behaviours) and so this may also be desirable. Though a slighter longer measure (20
items), the DFS has been found to be a valid and reliable measure of anxiety in
16
children over the age of 8 years old. If the clinician wants an immediate reflection of
how the child is feeling, then a state measure such as the Facial Image Scale may be
appropriate as it is immediate, easy to administer and score and can be used with
even very young children. However, it should be noted that this measure (and others
like it) is limited in the information it provides to the practitioner.
Choosing a measure for survey or research purposes will depend on the research
question being tested.
However, such studies should demonstrate that the scale
employed has good reliability and validity. Measures such as the MCDAS, CFSS-DS
and DAS/MDAS have demonstrated acceptable psychometric properties and been
employed in previous longitudinal and experimental studies [2, 15, 55, 64-66].
At a service organisation level a valid and reliable trait measure with established cutoffs is desirable, to enable practitioners to make appropriate referrals and so that
providers and commissioners can plan for the numbers of highly anxious patients
referred to secondary care services. Measures such as the MCDAS and CFSS-DS
may be helpful for this purpose, though it should be noted that younger children may
need help with understanding some of the items and response format. The faces
version of the MCDAS may be helpful for younger patients, although very young
children will still need to be assisted with completion.
It should be recognised, however, that many of the self-report measures which have
been used with children had a limited focus (e.g. situational triggers of dental anxiety)
and have not been based on a theoretical framework of dental anxiety. The lack of
consideration of the theoretical underpinnings of dental anxiety has previously been
highlighted with reference to measures of dental anxiety [9]. The Five Areas Model of
anxiety highlights the interrelationship between an individual’s unhelpful thoughts,
17
physical symptoms, behaviours, feelings and situational factors (e.g. parental anxiety)
and the importance of assessing these different aspects of dental anxiety [23]. Indeed,
if a child’s dental anxiety is to be treated then it has been argued that the factors which
contribute to their dental anxiety need to be understood [67]. Measures which only
assess a specific component of dental anxiety may produce an incomplete picture of
an individuals’ anxiety [39]. The DFS and S-DAI were the only measures employed
which assessed multiple aspects of children’s dental anxiety (e.g. unhelpful thoughts,
behaviours and physical symptoms).
In addition, five of the measures used to assess children’s dental anxiety had either
fully or partially been developed to assess the dental anxiety of adults. Many of the
early measures of child health-related quality of life were also adapted from adult
measures with concerns later expressed about their validity as the items included and
language used were not found to be relevant or appropriate for children [68]. Further
examination of the content and developmental validity (i.e. whether the measures,
comprehensively cover the domain of interest and make sense to child participants) of
measures of child dental anxiety are required. Cognitive interviewing techniques such
as the ‘think aloud’ procedure, which involves asking children to verbalise their
thoughts whilst responding to questionnaire items [69], could be used to test how well
children of different ages are able to understand and complete measures of dental
anxiety.
It should also be noted that none of the studies reviewed employed measures of
dental anxiety with children who have learning disabilities. This patient group may
experience particular difficulty expressing their fears and articulating their concerns.
Previous research has identified that individuals with learning disabilities do report
notable anxieties relating to dental examinations and treatments such as being afraid
18
of losing control and having difficulty complying with instructions [70]. The
development of an anxiety measure for children with learning disabilities could serve
as a valuable communication aid and promote effective child-centred management of
dental anxiety in this group of patients.
Conclusion
To conclude, dental anxiety and fear-related behaviours in children provide challenges
for clinicians and dental public health practitioners. With a need for a clear
understanding of the severity and nature of children’s dental anxiety the findings from
this systematic review can be used to help guide dental academics, clinicians,
psychologists and epidemiologists choose the most appropriate measure of dental
anxiety for their intended use. Future work should involve evaluating the content and
developmental validity of existing measures with further consideration given to the use
of theoretical frameworks to develop this field.
19
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23
95.
96.
97.
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24
Table 1. Advantages of conducting an assessment of children’s dental anxiety
Patient level





Increase patient’s and dental teams’
understanding of the factors contributing to
patient’s anxiety
Act as a communication aid between the
patient and the dental team
Completed measure/assessment can be
stored in patient’s notes as a way of
information sharing within the dental team
Helps dental team differentiate anxiety
from behavioural issues
Assessment can inform management
approaches so that interventions directly
target areas which are maintaining the
child’s anxiety (e.g. unhelpful thoughts,
specific triggers)
Service organisational level




Assess appropriateness of dental referrals
into a service (e.g. severity of dental
anxiety)
Assess effectiveness of specific
management approaches in reducing
children’s dental anxiety (behavioural
interventions, pharmacological methods)
Collect information on numbers of dentally
anxious children referred into services
Collect information on numbers of dentally
anxious children receiving specific
management approaches with a service
(e.g. sedation, general anaesthesia)
Epidemiology/Dental Public Health




Investigate prevalence of dental anxiety in
children and trends in prevalence over time
Examine risk factors and symptoms of
dental anxiety
Evaluate the effectiveness of interventions
to manage/reduce anxiety
Examine relationships between dental
anxiety and oral health outcomes (e.g.
clinical status, oral health related quality of
life, treatment satisfaction)
25
Table 2. Description of dental anxiety measures which studies have employed to assess children’s dental anxiety
Measure
Children’s Fear
Survey Schedule
Dental Subscale [43]
Number of items & scoring
No of items: 15
Scoring: 1=No fear to
5=Very frightened
Range: 15-75
Cut off: >32 anxious, >38/39
highly anxious
Development
Designed for:
Children
Child
involvement:
No
Means reported
Clinical: 22.545.1
Population:
22.9-36.7
Dental Anxiety
Scale [47] &
Modified Dental
Anxiety Scale [62]*
No of items: 4 or 5*
Scoring: Variety of response
statements to choose from
& 1=Not anxious to
5=Extremely anxious*
Range: 4-20 & 5-25*
Cut off: 9-12 moderate
anxiety, 13-14 high anxiety,
15-20 severe anxiety
(phobia)
No of items: 8
Scoring: Relaxed=1 to
5=very worried
Range: 8 -40
Cut off: >26 anxious
Original
measure: Adult
Child
involvement:
No
Clinical: 7.1-9.5
& 10.8-13.5*
Population: 9.011.6
Original
measure: Child
Child
involvement:
Yes, to some
extent
Designed for:
Children
Child
involvement:
No
Clinical: 16.126.2
Population:
18.2-19.9
Studies: 10 [49, 50, 54,
55, 60, 61, 64, 94-96]
Age range: 4 to 17 years
Countries: UK
Clinical: 12.616.5
Studies: 7 [15, 22, 66, 97100]
Age range: 8 to 15 years
Countries: Nigeria and
USA
Designed for:
Children
Child
involvement:
No
Clinical: 1.6-2.5
Studies: 7 [4, 48, 51-55]
Age range: 3 to 18 years
Countries: Turkey and UK
Designed for:
Children
Child
involvement:
Yes, to some
extent
Clinical: 1.1-2.5
Population: N/I
Studies: 4 [48, 65, 84,
101]
Age range: 3 to 18 years
Countries: Turkey and UK
Original
measure: Adult
Child
involvement:
No
Clinical: N/I
Population:
40.6*
Studies: 4 [3, 6, 58, 90]
Age range: 8 to 18 years
Countries: Hungary,
Israel and Jordan
Original
measure: Child
Child
involvement:
Yes, to some
extent
Population:
18.0 & 21.9*
Studies: 2 [60, 61]
Age range: 4 to 15 years
Countries: UK
Modified Child
Dental Anxiety
Scale [49]
Dental Fear
Schedule Subscale
Short Form [43, 46]
Facial Image Scale
[48]
Venham Picture
Scale [56]
Dental Fear Survey
[57] & Modified
DFS* [58]
Smiley Faces
Programmes [60] &
Revised SFP [61]*
No of items: 8
Scoring: 1=No fear to
5=Very frightened
Range: 8-40
Cut off: >20 anxious
No of items: 1
Scoring: 5 faces: 1=most
positive face to 5=most
negative face
Range: 1-5
Cut off: N/I
No of items: 8 pictures
(each contains an anxious &
non-anxious boy)
Scoring: Anxious boy =1 or
non-anxious boy =0.
Range: 0-8
Cut off: N/I
No of items: 20 or 15*
Scoring: 1=No fear or
reaction to 4=great fear or
reaction Range: 15-60 or 2080*
Cut off: N/I
No of items: 4 or 5*
Scoring: 7 faces:1=most
positive face 5=most
negative face
Range: 4-28 & 5-35*
Cut off: N/I
Population: 2.33.0
Populations
Studies: 28 [5, 7, 11, 12,
28, 45, 52, 53, 60, 64, 65,
71-87]
Age range: 3.5 to 19
years
Countries: Bulgaria,
Croatia, Denmark,
Finland, Greece, Japan,
Netherlands, Sweden,
Turkey, UK and USA
Studies: 14 [2, 4, 6, 8, 13,
24, 76, 80, 87-93]
Age range: 5 to 19 years
Countries: Canada,
Croatia, Hungary, Israel,
New Zealand, Sweden,
Turkey, UK and USA
Dental Anxiety
Inventory – Short
Version [63]
No of items: 9
Original
Clinical: N/I
Studies: 1 [75]
measure:
Adult
Scoring: 1=complete
Age range: 5 to 12 years
Child
disagreement to 5=complete
Countries: Croatia
involvement:
agreement
No
Range: 9-45
Cut off: >33 high anxiety
N/I: No information available - based on the examination of information included within the studies reviewed
26
Table 3. Evaluation of dental anxiety measures which studies have employed to assess children’s dental anxiety
Measure
Reliability & Validity
Areas assessed
Children’s Fear Survey
Schedule Dental
Subscale [43]
Cronbach’s alpha: 0.8-0.9
Test-retest: 0.9
Concurrent validity: N/I
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
Dental Anxiety Scale [47]
& Modified Dental
Anxiety Scale [62]*
Cronbach’s alpha: 0.8
Test-retest: 0.7
Concurrent validity: N/I
Physical symptoms: Yes
Behaviours: No
Thoughts: Yes
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
Modified Child Dental
Anxiety Scale [49]
Cronbach’s alpha: 0.8
Test-retest: 0.5-1.0
Concurrent validity: significantly
correlated with CFSS-DS (r=0.8), SFPR (r=0.6) & DAS (r=0.7)
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
Dental Fear Schedule
Subscale Short Form [43,
46]
Cronbach’s alpha: N/I
Test-retest: N/I
Concurrent validity: significantly
correlated with clinical observations
(k=0.7-0.9)
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – trait dental anxiety
Life situation: Yes - triggers of anxiety
Facial Image Scale [48]
Cronbach’s alpha: N/A - 1 item
Test-retest: N/I
Concurrent validity: significantly
correlated with VPS (r=0.7)
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – state mood
Life situation: Yes – triggers of anxiety
Venham Picture Scale
[56]
Kuder-Richardson: 0.8
Test-retest: 0.7
Concurrent validity: N/I
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – state emotions (including
dental anxiety)
Life situation: Yes - triggers of anxiety
Dental Fear Survey [57]
and Modified DFS [58]
Cronbach’s alpha: 0.9
Test -retest: N/I
Concurrent validity: significantly
correlated with DAS (r=.8)
Physical symptoms: Yes
Behaviours: Yes
Thoughts: No
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
Smiley Faces
Programmes [60] &
Revised SFP [61]*
Cronbach’s alpha: 0.7-0.8
Test-retest: 0.8
Concurrent validity: significantly
correlated with CFSS-DS (r=0.6) &
MCDAS (r=0.6)
Physical symptoms: No
Behaviours: No
Thoughts: No
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
Dental Anxiety Inventory
– Short Version [63]
Cronbach’s alpha: N/I
Test-retest: N/I
Concurrent validity: N/I
Physical symptoms: Yes
Behaviours: Yes
Thoughts: Yes
Feelings: Yes – trait dental anxiety
Life situation: Yes – triggers of anxiety
N/I: No information available - based on the examination of information included within the studies reviewed
27