Evaluating the validity of the Index of Dental Anxiety and Fear (IDAF-4C+) in adults with severe dental anxiety

Dental anxiety is a common condition with severe consequences for oral health and health-related quality of life. The aim of this study was to evaluate the recently developed self-report scale Index of Dental Anxiety and Fear (IDAF-4C⁺) in adults with severe dental anxiety. A sample of 147 adults (age 20–71 yr) with severe dental anxiety completed a questionnaire including the IDAF-4C⁺ and three other dental anxiety scales. In a clinically assessed subgroup (n = 93), 95% had an International classification of diseases and related health problems 10th version (ICD-10) diagnosis of specific phobia for dentistry. Agreement between the scales was analysed using Spearman’s correlation, the Kappa measure of agreement and the intraclass correlation coefficient. The agreement of dental phobia according to the IDAF-4C⁺ phobia module and the ICD-10 was very low (ĸ = 0.02). The anxiety and fear module of the IDAF-4C⁺ showed acceptable agreement with the other scales (r_s 0.69–0.75; ICC 0.90, 95% CI 0.87–0.93). We conclude that the IDAF-4C⁺ offers more information to clinicians and researchers than the older dental anxiety scales, but the phobia module needs further development.     

Prevalence of dental fear and phobia relative to other fear and phobia subtypes

The purpose of the present study was to estimate the point prevalence of dental fear and dental phobia relative to 10 other common fears and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR subtypes of specific phobia. Data were also analysed to examine differences with regard to severity, presence of distressing recollections of fear-related events, gender, and prevalence across age. Data were obtained by means of a survey of 1,959 Dutch adults, 18–93 yr of age. Phobias were assessed based on DSM-IV-TR criteria, whereas severity of present fears was assessed using visual analogue scales. The prevalence of dental fear was 24.3%, which is lower than for fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%). Among phobias, dental phobia was the most common (3.7%), followed by height phobia (3.1%) and spider phobia (2.7%). Fear of dental treatment was associated with female gender, rated as more severe than any other fear, and was most strongly associated with intrusive re-experiencing (49.4%). The findings suggest that dental fear is a remarkably severe and stable condition with a long duration. The high prevalence of dental phobia in the Netherlands is intriguing and warrants investigation in other countries.     

Acceptability of behaviour therapy for dental phobia

Forbes MDL, Boyle CA, Newton T. Acceptability of behaviour therapy for dental phobia. Community Dent Oral Epidemiol 2012; 40: 1–7. © 2011 John Wiley & Sons A/S Abstract – Objective: To determine how people with dental phobia rate the acceptability of behavioural therapy. Methods: One hundred and twenty individuals with dental phobia participated in a three‐factor experimental vignette‐based design. The three factors examined were dental treatment history, nature of intervention (intravenous sedation or behavioural therapy) and treatment outcome. There were eight different vignettes representing all combinations of the three experimental variables, and 15 participants completed each vignette. Results: Treatment outcome had a strong effect on rated acceptability (F = 115.76, P < 0.001). There was a weaker effect of treatment type (F = 5.49, P < 0.05) with behavioural therapy rated as more acceptable than intravenous sedation. Previous history of intravenous sedation was associated with a decreased perception that it is possible to overcome dental fear. Conclusions: The perceptions of individuals with dental phobia of the acceptability of behavioural approaches to management are influenced by the perceived outcome of the treatment.     

The extent and nature of dental fear and phobia in Australia

Background: For the general dental practitioner, fearful patients are harder and more stressful to treat and are most likely to attend irregularly. This study presents updated and refined dental fear and phobia prevalence estimates in Australia as well as information on the nature of dental fear and phobia. Methods: A total of 1084 Australian adults (response rate = 71.7%) completed a mailed questionnaire. The survey contained four measures of dental fear and phobia, as well as questions regarding potentially anxiety‐eliciting dental stimuli and past aversive dental experiences. Results: The prevalence of high dental fear ranged from 7.8% to 18.8%, and more incapacitating dental phobia from 0.9% to 5.4%, depending upon the scale, cut‐point and specific criteria used. Dental phobia was significantly associated with blood‐injection‐injury (BII) concerns. The cost of dental treatment was endorsed as the most anxiety‐eliciting dental situation (64.5%), followed by fear of needles/injections (46.0%) and painful or uncomfortable procedures (42.9%). Anxiety‐eliciting stimuli and the type of aversive dental experiences varied significantly by gender, age, income, education, language spoken at home and dental visiting frequency. Conclusions: High dental fear and dental phobia are common in Australia although prevalence estimates are highly dependent on both the scale and cut‐points used.     

The relationship between temperament and fearfulness in adult dental phobic patients

BACKGROUND: Temperament has been associated with dental fear (DF) and dental behavioural management problems (DBMP) in children, but little is known about what role temperament plays in the aetiology of DF. Thus, measures of temperament suitable for use among children, adolescents, and adults would be of value for longitudinal and family studies of DF, where relations between children's and parent's ratings are investigated. AIM: Our aim was to explore the adapted EASI (emotionality, activity, sociability, and impulsivity) in adult patients, and to evaluate the instrument in comparison with established measures of DF and general emotional reactions in adults. DESIGN: The subjects were 230 adult patients applying for treatment for DF and 41 nonfearful patients (reference group). Questionnaires investigated temperament (general and DF) and general anxiety and depression. RESULTS: The previously described factor structure of the EASI among children was confirmed and the adapted EASI had acceptable psychometric qualities. Emotionality correlated with DF and with measures of general psychological distress. No differences were found in mean scores of EASI dimensions between DF group and the reference group, which was in contrast with studies in children. CONCLUSIONS: The adapted EASI seem promising for use in future longitudinal and familial studies of development of DF and DBMP.     

A comparison of three continuous scales used to determine the prevalence of clinically significant dental fear

Armfield JM. A comparison of three continuous scales used to determine the prevalence of clinically significant dental fear. Community Dent Oral Epidemiol 2011; 39: 554–563. © 2011 John Wiley & Sons A/S Abstract – Objective: To assess the level of agreement and concordance of three different dental anxiety and fear scales and determine whether using commensurate cut‐points reduces discrepancies in the estimated prevalence of high dental fear. Methods: A representative sample of the Australian adult population completed a computer‐assisted telephone interview (CATI) with additional data obtained on a random sample of 25% of those completing the CATI. Participants completed three measures of dental anxiety and fear: the Dental Anxiety Scale, the Index of Dental Anxiety and Fear, and a single‐item question. Cut‐points were determined to equivalize the range of possible score responses defining a case of high dental fear for each scale. Results: A total of 1084 people completed the CATI and returned a questionnaire (response rate = 71.4%). Prevalence estimates ranged from 7.3% to 28.4% depending upon both the scale and cut‐point used. The overall percent agreement between the scales was high, but the overlap between the scales in those people determined to have high dental fear was considerably lower. Using different cut‐points to define a case significantly altered the sensitivity and specificity of the scale in predicting dental avoidance, problem‐oriented visiting and fear of lack of control. Conclusions: Equivalizing scale cut‐points does reduce variation in prevalence estimates of high dental fear across scales, but variation remains because of differences in the nature of, and content covered by, each scale. Dichotomizing scores on continuous scales to obtain prevalence estimates of high dental fear should be appropriately justified, correctly interpreted and supplemented by results describing the distribution of scores.     

Epidemiologic study of dental fear in school children 8-15 years of age

Authors investigated the dental fear scores (DAS, DFS) of 139 primary school children in Budapest, Hungary (72 females, 67 males, ages between 8-15 years). Sex and age had no effect on the scales. Mean dental fear scores were high (DAS: 10.7 +/- 3.7, DFS: 40.4 +/- 15.3). A strong correlation between DAS and DFS, and somewhat lower correlation between these scales and the general anxiety scales were demonstrated. Children's evaluation of the dental fear of the family and relations strongly correlated with dental fear and moderately with general anxiety. The results indicate that, dental fear is influenced by dental fear of family and relations, and general anxiety, but much less influenced by other demographic variables (i.e. age, sex) in primary-school children.     

Common use of a Fear Survey Schedule for assessment of dental fear among children and adults

BACKGROUND: Little is known about children with dental fear (DF) in a long-term perspective. Measures of DF suitable for use among children, adolescents, and adults would be of value for longitudinal and family studies. AIM: Our aim was to explore the DF subscale of the Children's Fear Survey Schedule (CFSS-DS) in highly fearful adult dental patients. DESIGN: The subjects were 230 adult patients applying for treatment for severe DF at a specialized DF clinic. Questionnaires investigated background data, general fear and DF, and general anxiety and depression. Reference data were obtained from 36 nonfearful patients on a subset of questionnaires. RESULTS: The fearful group reported high levels of DF on all measures and at a level similar to children with severe DF. The DF measures clearly differed between the fearful and reference groups. A factor analysis revealed a three-factor structure (fear of dental treatment, medical treatment, and of strangers and choking), which explained 68% of the variance. CONCLUSION: The CFSS-DS appears suitable for use in studies of adult populations. The results indicated that some areas of DF (physiology, avoidant behaviour, anticipatory anxiety), areas of importance among adult patients, are not assessed by the CFSS-DS. Studies of adults should therefore also include established adult measures of DF.     

A dental phobia treatment within the Swedish National Health Insurance

Severe dental fear/phobia (DF) is a problem for both dental care providers and for patients who often suffer from impaired oral health and from social and emotional distress.The aim of this paper was to present the Swedish model for DF treatment within the National Health Insurance System, and to describe the dental phobia treatment and its outcome at The Dental Fear Research and Treatment Clinic (DFRTC) in Gothenburg. A literature review was made of relevant policy documents on dental phobia treatment from the National Health Insurance System and for V?stra G?taland region on published outcome studies from DFRTC. The treatment manual of DFRTC was also used. In Sweden, adult patients with severe DF are able to undergo behavioral treatment within the National Health Insurance System if the patient and caregivers fulfil defined criteria that must be approved for each individual case. At DFRTC dental phobia behavioral treatment is given by psychologists and dentists in an integrated model. The goal is to refer patients for general dental care outside the DFRTC after completing treatment. The DF treatment at DFRTC has shown positive effects on dental fear, attendance and acceptance of dental treatment for 80% of patients. Follow-up after 2 and 10 years confirmed these results and showed improved oral health. In addition, positive psychosomatic and psychosocial side-effects were reported, and benefits also for society were evident in terms of reduced sick-leave. In conlusion, in Sweden a model has been developed within the National Health Insurance System helping individuals with DF. Behavioral treatment conducted at DFRTC has proven successful in helping patients cope with dental care, leading to regular attendance and better oral health.     

Sedation with nitrous oxide in daily practice

Conscious sedation is recommended, together with behaviour management techniques, to facilitate treatment of dental fear or dental phobia patients. In this article the authors focus on inhalation sedation by means of nitrous oxide. The procedures and indications are explained and illustrated with clinical cases. On the strength of the literature and their own experience the authors reach the conclusion that Inhalation sedation is a kind of pharmacological behaviour management and an important additional tool to increase patient cooperation. Inhalation sedation can only be performed by trained practitioners under internationally accepted safety conditions. Inhalation sedation has a future in Belgium providing the appropriate law is adapted. This technique deserves a place in the dental curriculum.     

Fear of COVID-19 in Madrid. Will patients avoid dental care?

IntroductionThe objective of this research is to describe how perceived infectability, germ aversion, and fear of COVID-19 in adults in Madrid have changed from the beginning of the pandemic until the lockdown exit phase and their influence on dental care behaviour.Materials and MethodsSome 961 participants were monitored in a study in Madrid at 2 time points: before lockdown (T0) and after completion of the total lockdown (T1). A questionnaire that included basic sociodemographic variables, the perceived vulnerability to disease scale (including perceived infectability and germ aversion), the fear of COVID-19 scale, and dental visiting behaviour after confinement for fear of COVID was administered.ResultsThe participants had higher scores for infectability and germ aversion at T1 than at T0 (P < 0.01). Of those studied, 24.5% (235) of the participants would not go to the dentist for fear of COVID-19. Those who had a high perceived infectability scale score were at least 5 times more likely to not visit the dentist. Those with high COVID-19 fear were at least 6 times more likely to not visit the dentist, and those older than 60 years were 8 times more likely to not visit.ConclusionsThe population's high levels of vulnerability to infectability and perceived germ aversion associated with fear of COVID-19 and the resultant avoidance behaviour to dental care will remain until an effective drug or vaccine for SARS-CoV2 is found.     

Dental caries and externalizing behaviour problems in a high‐risk child population

The aim of this study was to assess the association between externalizing behaviour problems and dental caries in children. A further objective was to explore direct and indirect pathways between sociodemographic factors, family functioning and parenting factors, oral health behaviours, externalizing behaviour problems, and dental caries using structural equation modelling. Cross‐sectional data were collected on 251, 5‐ to 8‐yr‐old children from a paediatric dental practice in the Netherlands. Children's decayed, missing, and filled primary teeth (dmft) scores were obtained from their dental records. Validated self‐report questionnaires were used to collect sociodemographic, behavioural, and family‐related data. Externalizing problem behaviour was significantly associated with a higher dmft score [incidence risk ratio (IRR) = 1.19; 95% CI: 1.06–1.34], but this association did not remain significant after adjustment for sociodemographic factors (IRR = 1.11; 95% CI: 0.99–1.26). A valid path model was presented after applying some modifications. Findings from the model suggest that it is plausible that child behaviour problems are directly associated with dental caries via toothbrushing behaviour. The model also provided support that maternal education level, the restrictiveness and warmth of parenting, and the communication of the family, play an indirect role in the association between children's externalizing behavioural problems and dental caries experience.     

Factors associated with dental behaviour management problems in children aged 2-8 years in Beijing, China

International Journal of Paediatric Dentistry 2011; 21: 200–209 Aim. This study determined the prevalence of children’s dental behaviour management problems (BMP) in our clinic, investigated the influence of non‐dental and dental background variables on BMP, and analysed the predictive power of these variables. Design. The study group included 209 children aged 2–8 years who received dental treatment. Interviews were conducted with accompanying guardians. Children’s dental behaviour was rated by a modified Venham’s clinical anxiety scale and a cooperative behaviour rating scale. Regression models were used to analyse behavioural and interview data and to calculate the power of background variables to predict children’s dental behaviour. Results. During the first treatment, 29.7% of children displayed BMP. Four variables were found to predict BMP in 87.9% of cases. The risk factors for BMP were younger age, negative guardian expectations of the child’s behaviour during treatment, anxiety or shyness around strangers, and presence of toothache. Children aged 2.5–3.5 years who attended kindergarten showed better dental behaviour than those who did not. Conclusions. This study is the first to report BMP prevalence in mainland China. Our results indicate that a simple pre‐treatment interview could provide data allowing the dentist to identify children with special dental behavioural needs.     

Assessment of patients with direct conditioned and indirect cognitive reported origin of dental fear

This study investigated the reported conditioned or cognitive origin of dental phobia in 100 adult patients at a specialized dental phobia clinic. It was shown that a majority of patients reported a conditioned background to their dental fear. Patients'avoidance time and level of dental anxiety corresponded to previously reported data for fearful groups. Individuals with an aruosal conditioning etiology of dental fear reported significantly longer avoidance time as compared to individuals with a cognitively learned reaction. With the exception of an elevated level of general fears, most psychometrically assessed emotional reactions were well within normal ranges. However, patients with a non-conditioned, cognitive etiology reported significantly higher levels of trait anxiety and fear of embarrassment. In addition, a separate analysis among women revealed a greater fear of physical injuries among patients with cognitive etiology.     

Relaxation vs. cognitively oriented therapies for dental fear

Cognitive therapy has been reported for the treatment of dental phobia, but comparisons with other behavioral treatments are scarce. This study investigated the outcome of two modes of treatment for phobic dental fear. Relaxation and cognitively oriented therapy were compared in a sample of 112 adult fearful dental patients. The patient made questionnaire assessments of background and outcome variables, and the specialist dentist rated successful/non-successful outcome. It was shown that a higher number of patients who received cognitively oriented therapy completed the treatment program, while anxiety was more reduced among patients who received relaxation-oriented therapy. Dropout during the initial phobia therapy with a psychologist was related to lower motivation (willingness to engage in treatment), while failures during dental treatment after the completion of therapy were related to higher levels of general fear and anxiety. A multiple logistic regression model explaining 67% of the variance revealed that the risk of failure was only slightly increased by general fears, while patients with low (below median) motivation ran a 3.6-times-higher risk of dropping out. In conclusion, it was shown that the two treatment methods were both effective in reducing dental phobic reactions. However, while cognitively oriented therapy resulted in a higher number of patients completing therapy, relaxation-oriented treatment generally resulted in a more significant reduction in dental fear as well as in general anxiety and fear. Motivation was found to be a significant predictor of successful treatment outcome.     

Behavioural and emotional problems in children referred to a centre for special dental care

This study was conducted among 203 children (103 boys) referred to a centre for special dental care because of a high level of dental fear. It was undertaken to explore to what extent behavioural and emotional problems co-exist in these children compared with children of a Dutch norm group. The children's parents filled out the parental version of the Child Behaviour Checklist (CBCL), before their first appointment at the centre. The behavioural and emotional problems of the children were assessed by this CBCL, and the mean scores of the children in the study were compared with the mean scores of the norm group. The mean scores on all scales, except on the subscale 'sex problems', of the children with a high level of dental fear proved to be significantly higher than the mean scores of the norm group (P< or =0.001). The results indicated that children referred to a special dental care centre not only suffer from high dental fear but also have problems in several other behavioural and emotional areas. These problems appear to be heterogeneous; they were found in several specific problem areas, both external and internal.     

Psychosocial aspects of dental and general fears in dental phobic patients

Phobic reactions can often be a significant health problem for fearful dental patients. This is true in particular for individuals with long-time avoidance and elevated general psychological distress. The aim of this study was to investigate the expression of dental fear among 67 dental phobic individuals with a low versus high degree of general fear. Reported etiologic background factors, avoidance time, general psychological distress and psychosocial manifestations and consequences of dental phobia were studied. No significant difference in dental anxiety level between individuals with low versus high general fear was found, and both groups reported high frequencies of negative dental experiences. The low-fear group reported a longer (though not statistically significant) average avoidance time than the high-fear group. However, patients with a high level of general fear showed a significantly higher degree of psychological distress, and also reported stronger negative social consequences from their dental anxiety. These results indicate that the character of dental fear might be different between different groups of fearful patients, which makes the condition psychologically handicapping. Such aspects should be assessed in the diagnostic analysis of patients with severe dental anxiety. In particular, assessments of signs of general psychological distress are warranted.     

Psychosocial aspects of dental and general fears in dental phobic patients

Phobic reactions can often be a significant health problem for fearful dental patients. This is true in particular for individuals with long-time avoidance and elevated general psychological distress. The aim of this study was to investigate the expression of dental fear among 67 dental phobic individuals with a low versus high degree of general fear. Reported etiologic background factors, avoidance time, general psychological distress and psychosocial manifestations and consequences of dental phobia were studied. No significant difference in dental anxiety level between individuals with low versus high general fear was found, and both groups reported high frequencies of negative dental experiences. The low-fear group reported a longer (though not statistically significant) average avoidance time than the high-fear group. However, patients with a high level of general fear showed a significantly higher degree of psychological distress, and also reported stronger negative social consequences from their dental anxiety. These results indicate that the character of dental fear might be different between different groups of fearful patients, which makes the condition psychologically handicapping. Such aspects should be assessed in the diagnostic analysis of patients with severe dental anxiety. In particular, assessments of signs of general psychological distress are warranted.     

Helping your patients overcome dental phobia

Dental phobias stem from various sources and can lead to strongly conditioned fear responses. The following are the most common origins of dental fear: Previously painful or negative experiences during visits to a dentist's office. A severe discomfort with feeling vulnerable and/or out of control in a dental situation. A sense of embarrassment from dental neglect and fear of ridicule and/or belittlement. Scary anecdotes of negative dental experiences from family and friends. Negative, menacing portrayals of dentists in movies, television, newspapers, and magazines. A sense of depersonalization in the dental process, intensified by today's necessity for the use of barrier precautions, such as masks, latex gloves, and shields. A general fear of the unknown. Once you recognize the possible sources of your patients' fears, you will be in a much better position to help them identify and overcome their particular brand of dental phobia.     

Correlates of success and failure in behavior therapy for dental fear.

Extreme dental fear and avoidance are universal problems, with severe adverse effects on the patient's oral health. Although behavior modification techniques were shown to be effective in the treatment of this problem, their success is by no means absolute. In the present article, the SCL-90 questionnaire was used for development of possible predictive measures for success and failure of behavior modification as a treatment for dental fear. Patients who failed in treatment through behavior modification were found to score significantly higher on the global score of Positive Symptom Distress Index (p < 0.01) and on individual subscales of somatization (p < 0.02) and psychoticism (p < 0.05) than patients who were treated successfully. The predictive value of chosen SCL-90 scales was 71%. The results suggest that use of SCL-90 may be valuable for the prediction of success and failure of behavior modification as a treatment for dental fear and avoidance.