Dental fear and anxiety in an adult Icelandic population

Einar Ragnarsson
Institute of Dental Research, University of Iceland, ReykjavõÂk, Iceland

Ragnarsson E. Dental fear and anxiety in an adult Icelandic population. Acta Odontol Scand 1998;
56:100±104. Oslo. ISSN 0001-6357.
This study was carried out on a random sample drawn from participants in a population-based survey in
ReykjavõÂk, Iceland. The sample consisted of 1548 people, men and women, born in 1914±63 (age range,
25±74 years) who lived in and around ReykjavõÂk and a rural area in southern Iceland. The results from a
single, modified Dental Anxiety Question (DAQ), designed to classify fear or anxiety into five different
levels or categories, were compared with respect to age, oral status, extent of edentulousness, and
education level. Of the whole sample 10% admitted to having considerable or more than considerable
fear, while 5% classified their fear as extensive or more than extensive. Only 0.3%, however, said that it
prevented dental visits. Fear was influenced by sex, as significantly more women experienced some level of
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fear (P < 0.001) and described their fear as considerable or extensive (P < 0.001). Fear was more common
in the younger age groups among both sexes. A significant correlation was found between the number of
decayed teeth and anxiety among the men, and patients of both sexes who admitted to fear had
significantly fewer fillings. Fear was significantly more common in the rural than the urban population
(P < 0.001). Edentulousness, or number of remaining teeth, did not seem to be significantly reflected in the
extent of dental fear. People with higher education levels reported less dental fear. & Dental anxiety;
epidemiology, oral; oral health
Einar Ragnarsson, Institute of Dental Research, University of Iceland, VatnsmyÂrarvegi 16, 101 ReykjavõÂk, Iceland

In spite of tremendous advances in dentistry with ICA (17). The study was carried out in the years 1989±90.
improved anesthetics, instrumentation, and techniques, The participants were born in 1914±63 (age range, 25±74
For personal use only.

fear of dental services is still prevalent and freely admitted years). The MONICA survey participants answered
to by many people. In a study by Agras et al. (1), the numerous questions in relation to risk factors associated
prevalence of dental fear or phobia was shown to be 198/ with cardiovascular disease; since this was the primary aim
1000, or as high as the fear of flying, and ranks 4th or 5th of participation in the study, there were unavoidable
among 40 commonly feared situations. The prevalence has limitations to the length of the questionnaire.
been within the range of 4%±15%, as reported in previous Owing to with these limitations, a slightly modified
investigations (2±5). Dental Anxiety Question (DAQ) was used, as dental fear
Many have found a relationship between dental fear was to be assessed with a single question (14). Like the
and fearfulness in general (1, 2, 6±14). Several scales and other MONICA survey questions, the DAQ question was
psychometric measures have been used in assessing dental answered verbally in the presence of an interviewer who
fear over the years (3, 13±16). then interpreted the answers and classified them into five
Dental phobia has been defined as a special kind of fear categories. The question was, `Do you experience anxiety
that is out of proportion to the demands of the situation, or fear in relation to visiting a dentist?' The answers given
will not respond to reason, is apparently beyond voluntary were classified into the following four options: 1) No; 2) A
control, and leads to avoidance of dental treatment. little; 3) Yes, quite (considerable); and 4) Yes, very
However, some investigators have considered dental fear (extensive). The patients admitting to any fear answered
or anxiety normal, unless it is of such a degree that it with a simple yes or no regarding whether their fear
interferes with much-needed dental care (7). prevented their seeking dental services, which has been
The extent of dental fear or phobia among the Icelandic looked upon as a fifth option. The participants answered
population has been given little consideration. The aim of 34 other questions asked by the same interviewer, using a
this study was to investigate to what extent it affected the standardized questionnaire on oral health, dental visiting
adult Icelandic population and to see if the methods would habits, and oral hygiene.
reveal a prevalence of dental anxiety within the range An oral examination was carried out at the same time
reported from previous studies in neighboring countries. by a trained employee (oral hygienist), using a mouth
mirror, a dental probe, and a special periodontal probe
recommended by WHO (18).
Materials and methods The information gathered included the number and
position of decayed, missing, and filled teeth (DMFT) and
The sample, which consisted of 720 men and 828 women, a Community Periodontal Index of Treatment Needs.
was randomly drawn from a group selected for a World Crowns, bridges, and removable partial and complete
Health Organization (WHO) project, code named MON- dentures were also noted.
 ACTA ODONTOL SCAND 56 (1998) Dental fear in Iceland 101
As the sample was originally selected randomly within Table 1. The sample by age and sex
the respective age groups (with data-gathering on heart
Age (years) Women Men Total
disease as a primary aim), age standardization was carried
out using the world standard population (19). 25±34 148 105 253
The significance of differences between groups was 35±44 163 144 307
tested by calculating the ratio between age-adjusted 45±54 166 165 331
55±64 182 149 331
figures. The logarithm of a ratio was assumed to have 65±74 169 157 326
normal distribution, and its variance was estimated as the Total 828 720 1548
sum of the reciprocals of the underlying numbers (20).
Linear regression analysis was carried out to test the
association between fear and oral health status (the
components of the DMFT index), controlling for educa- corresponded with lower incidence of total edentulousness
tion level. and higher number of remaining teeth. The difference
regarding higher level of education and lower DMFT
score was statistically significant (P < 0.001). It was also
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verified that the number of decayed teeth increased with

Results higher level of admitted fear (P = 0.006). The association
The age and sex distributions of the sample are presented between fear and oral health was not confounded by
in Table 1. Both sexes were classified by age and subjective education level. In multivariate analysis dental anxiety
estimation of fear (Table 2). It can be seen that almost stayed significant, even when controlling for education
29% admitted some fear, ranging from `a little' to the level.
extent that it would prevent a visit to a dentist. Of the total Multivariate analysis, using the D-component of the
10% admitted to having considerable or more than DMFT index as the dependent variable and dental fear as
considerable fear, while 5% considered their fear extensive the exposure variable, showed that the association between
or more than extensive. Only five patients, or 0.3%, said dental fear and number of decayed teeth stayed significant,
that their fear prevented them from seeking dental even when controlling for age, sex, residence, and
assistance. Fear was more common in the younger age education. Similar results were obtained when the F-
For personal use only.

groups for the sexes combined (P < 0.001); this was true for component of the DMFT index was used.
all levels of fear (Table 2).
Fear was more common among the rural population
(P < 0.001). Discussion
Women admitted to fear more frequently than did men
(P < 0.001), and this difference was consistent in all age The nature of dental fear has been a matter of dispute.
groups and at all levels of fear. When comparing the whole Some think it should be regarded as an anxiety state, while
sample for those who admitted having considerable or others maintain that it stands out as one of several fears
more than considerable fear, the significance by sex was and phobias among affected patients (2). Fearful dental
also high (P < 0.001). patients may not differ with respect to general fearfulness
The difference by age of those claiming no anxiety or in comparison with non-fearful patients. Dental fear,
fear was significant (P < 0.001) and was also significant for however, may exist as a specific fear or may be
all levels of fear for the women (P < 0.001), while for the accompanied by many fear-associated behaviors (3, 8).
men the difference was less significant (P = 0.01). The Dental fear may be expressed as a greater, but eventually
same values were considered for edentulous people. less accurate, prediction of pain or as lower-than-average
Edentulousness in one or both jaws did not seem to pain tolerance. It is unclear, however, whether or not the
reduce the fear±age±sex tendency to any extent. anxiety has its origin in a more intense pain experience,
No significant differences were found when the number such as during the first visit or an episode in childhood
of DMFT was compared with the level of fear and anxiety. (3, 7, 9, 13, 21, 22). It is obvious that the fear and anxiety
However, when the number of decayed teeth (D) was expressed by the patients of treatment in the dental office
tested separately against anxiety, a significant correlation is not fully understood. If fear is acquired it may be a
was found for the men (P < 0.001) and a lower, but not reaction to negative stimulation from the surroundings,
statistically significant, correlation for the women. When but, if innate, fear may be a part of the personality or a
tested against the number of filled teeth (F), patients of more general fear-related syndrome combined with other
both sexes who admitted to fear had significantly fewer fears and phobias (2, 23, 24).
fillings (P < 0.001). Several different methods have been used to help people
Level of education was considered. It may be taken as deal with the complicated psychologic and clinical
such or as an indication of the standard of living. Patients problems caused by dental fear. Psychologic, psychophy-
with a higher education level included a significantly siologic, hypnotic, behavioral, and pharmacologic treat-
higher number who claimed they had no fear at all ments have been described. The number of articles written
(women, P = 0.007; men, P = 0.02). Higher education also on the subject demonstrates that, even though the dental
 102 E. Ragnarsson ACTA ODONTOL SCAND 56 (1998)

Table 2. The whole sample, dentulous and edentulous, classified by extent of fear, sex, and age

None A little Considerable Extensive Prevents visit Total

Age (years) n % n % n % n % n % n %
Women
25±34 72 48.6 43 29.1 15 10.1 17 11.5 1 0.7 148 17.9
35±44 98 60.1 48 29.4 7 4.3 10 6.1 0 0.0 163 19.7
45±54 117 70.5 28 16.9 13 7.8 8 4.8 0 0.0 166 20.0
55±64 136 74.7 30 16.5 7 3.8 9 4.9 0 0.0 182 22.0
65±74 142 84.0 17 10.1 3 1.8 4 2.4 3 1.8 169 20.4
Total 557 67.8 166 20.2 45 5.4 48 5.8 4 0.5 828 100
Men
25±34 60 57.1 32 30.5 7 6.7 6 5.7 0 0.0 105 14.6
35±44 101 70.1 30 20.8 4 2.8 9 6.3 0 0.0 144 20.0
45±54 120 72.7 34 20.6 6 3.6 5 3.0 0 0.0 165 22.9
55±64 123 82.6 19 12.8 2 1.3 4 2.7 1 0.7 149 20.7
65±74 138 87.9 8 5.1 9 5.7 2 1.3 0 0.0 157 21.8
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Total 542 75.3 123 17.1 28 3.9 26 3.6 1 0.1 720 100
Total 1107 71.5 289 18.7 73 4.7 74 4.8 5 0.3 1548 100

profession is better equipped and educated to deal with to admit fear of dental treatment. Confirmation of this
dental anxiety than ever before, it still presents an conclusion has been reported by several investigators (2, 4±
important barrier to oral treatment that is difficult to 6, 10, 15, 20, 30±39), even though women in general tend
overcome (2, 3, 8±13, 25, 26). As stated by Berggren, `The to visit the dentist more regularly than men (34, 36±38).
manifestation of dental fear by patients in the dental office Others found no correlation with sex (10, 39). Schuurs &
is still far from fully understood' (3). The fear of dental Hoogstraten (15) have confirmed the greater experience of
For personal use only.

visits ranks high in any list of common fears (1, 4, 27), and dental fear among women in a study using Corah's Dental
in certain instances differences may be found between Anxiety Scale (DAS) (10, 14, 15). They claim that the
people of different races or origins (28). Excellent higher scores of women do not necessarily mean that
pharmacologic preparations are currently available that women are more anxious than men, but that they express
make treatment easier for people who express fear, as well anxiety more readily than men do. Lautch (7) found no
as for the dental personnel (27). However, drug therapy difference by sex before puberty, after which women
should be limited to the most serious cases. expressed greater tendency to fear.
Of the whole sample of 1548 patients, 10% (men, 6%; Like this study, several studies have found a relationship
women, 12%) admitted to having considerable or more between age and anxiety (2, 10, 15, 39). Vassend (5),
than considerable dental fear. Extensive or more than however, did not. Locker & Liddell (40) mention a certain
extensive fear was admitted to by 5% (men, 4%; women, indication that aging may influence the relationship
6%), while only 0.3% (men, 0.1%; women, 0.5%) said it between oral health status and dental anxiety. They also
prevented them from seeking dental services. mention that the difference in oral health status between
According to Agras the total prevalence of fear and dentally anxious and non-anxious subjects can be relatively
anxiety in general among 325 people from the Greater small in absolute terms, and indicate that the severity may
Burlington area was 8%. In the same population 7.7% decline with aging. A reduced level of dental fear with
were considered to be mildly disabled by the fear and aging is in agreement with findings from earlier studies
0.2% severely disabled (1). (2, 3, 10, 13). Hakeberg (2) also found a higher proportion
The reliability, validity, and interpretation of question- of anxiety in the age group 20±39 than in the younger as
naires have been matters of dispute (3, 8, 10, 14± well as the older age groups. Some surveys have shown a
16, 21, 29). Levine & De Simone (30), for instance, found correlation between level of education and social class,
that men reported significantly less general pain to a income, and dental anxiety (4, 10, 14), while contradictory
female experimenter than to another man, while women results have been reported by others (2, 4, 29, 32, 34, 37).
had a tendency to report greater pain to an experimenter Among the Icelanders, those with higher education more
of the opposite sex, though that difference was not frequently reported no fear, and none of them said that it
statistically significant. The use of many different scales, prevented visits to the dentist. The results of this
with or without modifications, as well as interpretation of investigation indicate, however, that even though people
the results, has also been discussed (3, 8, 10, 12± admitting more readily to fear have worse oral status in
14, 16, 21, 29). Do the scales measure what they are general, it cannot be explained by the effect of education
meant to? Assuming that the DAQ worked as expected, level alone.
the results of this study show that women are more willing Location (urban/rural) seemed to be of importance.
 ACTA ODONTOL SCAND 56 (1998) Dental fear in Iceland 103
This may eventually be explained by different accessibility Emotional imagery in simple and and social phobia: fear versus
and frequency of dental visits over the years. anxiety. J Abnormal Psych 1993;02:212±25.
12. Hakeberg M, Gustafsson JE, Berggren U, Carlsson SG. Multi-
The fearful patients in the present survey had more variate analysis of fears in dental phobic patients according to
decay and fewer fillings. Many reports indicate a relation reduced FSS II scale. Eur J Oral Sci 1995;103:339±44.
between oral health status and dental anxiety 13. Berggren U, Carlsson SG, Gustafsson JE, Hakeberg M. Factor
(2, 5, 6, 10, 14, 37, 39). In some studies dental fear has analysis and reduction of fear survey schedules among dental
been blamed on irregular dental visits as well as inferior phobic patients. Eur J Oral Sch 1995;103:331±8.
14. Neverlien PO. Dental anxiety in children and adults. Empirical
oral health status (2, 4, 5, 31, 38, 40±42). However, Mellor studies in Norway [thesis]. Bergen: University of Bergen; 1991.
(39) found no such correlation. He maintains that the 15. Schuurs AH, Hoogstraten J. Appraisal of dental anxiety and fear
reported time interval since the last check-up may be the questionnaires [review]. Community Dent Oral Epidemiol 1993;
most important predictor of the DAS score. Locker & 21:329±39.
Liddell (40) point out that even though their data showed a 16. Corah NL, Gale EN, Illig SJ. Assessment of a Dental Anxiety
Scale. J Am Dent Assoc 1978;97:816±9.
statistically significant relationship between oral health 17. WHO MONICA Project Principal Investigators. The world
status and dental anxiety, the difference was often organization MONICA project (monitoring trends and determi-
relatively small. According to Vassend (5), `many dentally nants in cardiovascular disease): a major international collabora-
Acta Odontol Scand Downloaded from informahealthcare.com by McMaster University on 11/05/14

anxious patients seek out and undergo dental treatment tion. J Clin Epidemiol 1988;41:105±14.
despite high fear levels.' He points out that even though 18. World Health Organization. Epidemiology, etiology, and pre-
vention of periodontal diseases. Geneva: WHO; 1978. Technical
dental anxiety is obviously important, it cannot account for report series 621.
an adequate differentiation between regular and irregular 19. Doll R, Payne P, Waterhouse J, editors. Cancer incidence in five
dental attendance. continents. Berlin: Springer Verlag; 1966.
In spite of vast medical and technologic improvements 20. Breslow NE, Day NE. Statistical methods in cancer research.
Vol II. The design and analysis of cohort studies. Oxford: Oxford
with respect to pain control and patient comfort during University Press; 1987.
recent years, the prevalence of dental anxiety and fear 21. Kleinknecht RA, Klepac RK, Alexander LD. Origins and
among different populations seems to have remained characteristics of fear of dentistry. J Am Dent Assoc 1973;86:
virtually unchanged over the past few decades, according 842±8.
to numerous investigations and surveys. Further investiga- 22. Shoben EJ, Borland L. An empirical study of the aetiology of
dental fears. J Clin Psychol 1954:171±4.
tion of the causes and possible treatment of this fear is
For personal use only.

23. Milgrom P. Increasing access to measures for prevention and

required. treatment of dental anxiety, fear and phobia: perspectives from a
dental school based fear clinic. Anesth Progr 1986;33:62±4.
Acknowledgements.ÐHelgi Sigvaldason and Sigurdur R. Sñmundsson 24. Arntz A, Eck M, Heijmans M. Predictions of dental pain: the fear
of the Icelandic Heart Association are thanked for their kind support. of any expected evil is worse than the evil itself. Behav Res Ther
The project was supported by the Research Fund of the University of 1990;28:29±41.
Iceland. 25. Hammarstrand G, Berggren U, Hakeberg M. Psychophysiolo-
gical therapy vs. hypnotherapy in the treatment of patients with
dental phobia. Eur J Oral Sci 1995;103:399±404.
26. De Jongh AD, Muris P, Horst GT, Van Zuuren F, Schoen-
makers N, Makkes P. Case histories and shorter communications.
References One-session cognitive treatment of dental phobia: preparing
dental phobics for treatment by restructuring negative cognitions.
1. Agras S, Sylvester D, Oliveau D. The epidemiology of common Behav Res Ther 1995;33:947±54.
fears and phobias. Compr Psychiatr 1969;10:151±6. 27. Malamed SF. Pain and anxiety control in dentistry [review]. J
2. Hakeberg M. Dental anxiety and health. A prevalence study and Calif Dent Assoc 1993;21:35±40.
assessment of treatment outcomes [thesis]. GoÈteborg: Faculty of 28. Domoto P, Weinstein P, Kamo Y, Wohlers K, Fiset L, Tanaka
Odontology, GoÈteborg University; 1992. A. Dental fear of Japanese residents in the United States. Anesth
3. Berggren U. Dental fear and avoidance. A study of etiology, Progr 1991;38:90±5.
consequences and treatment [thesis]. GoÈteborg: Faculty of 29. Kleinknecht RA, Thorndike RM, McGlynn FD, Harkavy J.
Odontology, GoÈteborg University; 1984. Factor analysis of the dental fear survey with cross-validation. J
4. Hakeberg M, Berggren U, GroÈndahl H-G. A radiographic study Am Dent Assoc 1984;108:59±61.
of dental health in adult patients with dental anxiety. Community 30. Levine FM, De Simone LL. The effects of experimenter gender
Dent Oral Epidemiol 1993;21:27±30. on pain in male and female subjects. Pain 1991;44:69±72.
5. Vassend O. Anxiety, pain and discomfort associated with dental 31. O'Mullane D, Whelton H, Gavlin N. Health services and
treatment. Behav Res Ther 1993;31:659±66. women's oral health. J Dent Educ 1993;57:749±52.
6. Berggren U. General and specific fears in referred and self- 32. Grabowski M. Den ñldre befolknings oralstatus og odontologiske
referred adult patients with extreme dental anxiety. Behav Res behandligsbehov i Vestsjñllands Amt [thesis]. AÊrhus: Faculty of
Ther 1992;30:395±401. Odontology, University of AÊrhus; 1974.
7. Lautch H. Dental phobia. Br J Psychiat 1971;119:151±8. 33. Moore R, Birn H, Kirkegaard E, Brùdsgaard I, Scheutz F.
8. Moore R, Brùdsgaard I. Differential diagnosis of odontophobic Prevalence and characteristics of dental anxiety in Danish adults.
patients using the DSM-IV. Eur J Oral Sci 1995;103:121±6. Community Dent Oral Epidemiol 1993;21:292±6.
9. Klingberg G, Berggren U, Carlsson SG, NoreÂn JG. Child dental 34. Haakansson J. Dental care habits, attitudes towards dental health
fear: cause-related factors and clinical effects. Eur J Oral Sci and dental status among 20±60 year old individuals in Sweden
1995;103:405±12. [thesis]. Lund: Bokforlaget Dialog; 1978.
10. Moore R. The phenomenon of dental fear [thesis]. AÊrhus: 35. Wardle J. Fear of dentistry. Br J Med Psychol 1982;55:119±26.
University of AÊrhus; 1991. 36. Ragnarsson E, O Â lafsson SH, ElõÂasson S Th. Munnferli karla 52
11. McNeil DW, Vrana SR, Melamed BG, Cuthbert BN, Lang PJ. ja-79 aÂra karla Âõ hoÂprannsoÂkn Hjartaverndar 1985±1986 [The
 104 E. Ragnarsson ACTA ODONTOL SCAND 56 (1998)

oral behavior of men 52±79 years old in a population survey of 39. Mellor AC. Dental anxiety and attendance in the North-west of
the Icelandic Heart Society 1985±1986]. Icelandic Med J England. J Dent 1992;20:207±10.
1988;74:403±9. 40. Locker D, Liddell A. Clinical correlates of dental anxiety among
37. Ragnarsson E, O Â lafsson SH, ElõÂasson S Th. Munnferli kvenna older adults. Community Dent Oral Epidemiol 1994;20:372±5.
52±79 aÂra Âõ hoÂprannsoÂkn Hjartaverndar 1986±1987 [The oral 41. Johansson P, Berggren U. A comparison of two psychometric
behavior of women 52±79 years old in a population survey of the instruments. Acta Odontol Scand 1992;50:43±9.
Icelandic Heart Society 1985±1986]. Icelandic Med J 1989;75: 42. Krochak M. The difficult denture patient [review]. Int J
405±13. Psychosom 1991;38:58±62.
38. Kleinknecht R, Bernstein DA. The assessment of dental fear.
Behav Ther 1978;9:626±34.

Received for publication 20 August 1997

Accepted 21 October 1997
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