International Dental Journal

SCIENTIFIC RESEARCH REPORT

doi: 10.1111/idj.12613

The prevalence and impact of dental anxiety among adult

New Zealanders
Ishani Sukumaran, Shay Taylor and W. Murray Thomson
Sir John Walsh Research Institute, Faculty of Dentistry, The University of Otago, Dunedin, New Zealand.

Objective: To describe the prevalence and impact of dental anxiety in the New Zealand adult population. Methods: Sec-
ondary analysis of data from the 2009 New Zealand national oral health survey. Dental anxiety was measured using the
Dental Anxiety Scale (DAS). Results: The prevalence of dental anxiety was 13.3% (95% CI = 11.4, 15.6). On average,
DAS scores were higher by 14% among females, lower among those in the oldest age group (55+), higher by 10%
among those in the European/Other ethnic category, and higher by 10% among those residing in the most deprived
neighbourhoods. Those who were dentally anxious had greater oral disease experience and were less likely to have vis-
ited a dentist within the previous 12 months. They also had poorer oral health-related quality of life, with the highest
prevalence of OHIP-14 impacts observed in dentally anxious 35- to 54-year-olds. Conclusions: Dental anxiety is a dental
public health problem. It is an important contributor to poor oral health and care avoidance among New Zealanders.
There is a need to develop both clinical and population-level interventions aimed at reducing the condition’s prevalence
and impact.

Key words: Dental anxiety, New Zealand, quality of life, dental utilisation

DAS and MDAS scales remain the most commonly

INTRODUCTION
used.
Dental anxiety is heightened fear or anxiety in the den- Through the longstanding Dunedin Multidisciplinary
tal setting. It is a public health concern because it is rela- Health and Development Study (DMHDS), New Zeal-
tively common and adversely affects the oral health of and has made important contributions to knowledge of
sufferers1. General population estimates for the preva- the antecedents, natural history and consequences of
lence of dental anxiety in developed countries range dental anxiety2,12, but the findings of that study are lim-
from 4% to 20%, with at least some of that variation ited to a single birth cohort. Understanding of the preva-
because of differences in the scales that have been used2. lence and associations of dental anxiety in the wider
People with dental anxiety tend to have more missing New Zealand population requires surveys of nationally
teeth, more untreated carious tooth surfaces, and poorer representative samples. Despite the country having had
oral health-related quality of life (OHRQoL)1,3–5. It three national oral health surveys to date13–15, none has
also contributes to a vicious cycle of dental avoidance, yet reported on dental anxiety. Current knowledge has
with dentally anxious individuals having poorer dental come largely from surveys of subnational samples. The
attendance and more appointment cancellations leading prevalence of dental anxiety among South Island West
to poorer oral health1,5–9. This burden is more apparent Coasters was estimated to be 20% two decades ago16,
in females and younger individuals1,6,7. and a more recent survey conducted in Dunedin by Ibra-
A number of dental anxiety scales are available9, him and colleagues observed a similar prevalence9. Den-
with the Dental Anxiety Scale (or DAS)10 and the tal anxiety was more common among women in the
modified Dental Anxiety Scale (MDAS)11 having been latter study, but there were no apparent differences by
most frequently used, despite their limitations. The education level or socioeconomic status. Dentally anx-
IDAF-4C (Index of Dental Anxiety and Fear scale) ious individuals had less favourable dental visiting pat-
was designed to overcome the limitations of the ear- terns. Use of the self-report approach meant that neither
lier scale and is more theoretically robust5, but its use that study nor the West Coast one was able to examine
in dental anxiety research is not yet extensive9. The the clinical associations of dental anxiety.
© 2020 FDI World Dental Federation 1
Sukumaran et al.

The 2009 New Zealand Oral Health Survey clinical examinations conducted by dental examiners.
(NZOHS) gathered self-report and clinical oral health- The 2009 NZOHS clinical team comprised a lead
related information from New Zealand adults, includ- examiner and 22 dental examiners, including a gold-
ing data on dental anxiety15, but the dental anxiety standard examiner. All dentists (including the lead
data have yet to be reported (largely due to resource examiner and gold-standard examiner) were fully
constraints). Contemporary knowledge of the condi- qualified and registered, and held current Annual
tion’s prevalence and associations is essential for Practising Certificates. In total, the dental examiners
enabling adjustment of dental care services so that they completed 2,209 examinations of adults aged 18 years
are responsive to the needs of the many thousands of or more. Further information on the NZOHS design
people who are dentally anxious9. Accordingly, this can be found in the Ministry of Health’s 2009 Oral
study aimed to describe the prevalence and impact of Health Survey Methodology report.17
dental anxiety in the New Zealand adult population. The NZOHS received ethical approval from the
NZ Health and Disability Multi-Region Ethics Com-
mittee. Further ethical approval was not required for
METHODS
this secondary analysis because the data gathered
Oral health data in the 2009 New Zealand Oral Health from the original survey were accessed under the Min-
Survey (NZOHS) were collected between February and istry of Health’s established confidentialised unit
December 2009. The sampling frame for the 2009 record files (CURF) protocol.
NZOHS was households which had taken part in an
earlier national health survey, the 2006/07 New Zeal-
Statistical analyses
and Health Survey (NZHS), which surveyed the usu-
ally resident civilian population of all ages living in The statistical programme Stata (version 15.1) for
permanent private dwellings in New Zealand (and also Windows (Stata Corp, College Station, TX, USA) was
collected some self-report oral health data). Only used in these secondary data analyses. Survey data
households that had given permission to be re-con- weights were used. After calculating DAS scores by
tacted for future health-related surveys were included. summing the responses to the four items, we exam-
Of the 12,488 adults who took part in the 2006/07 sur- ined first the occurrence of dental anxiety and then
vey, 84% consented to recontact for subsequent sur- the consequences of it. Cross-tabulations were used in
veys. Of those, 3,475 took part, and 2,209 of those describing its prevalence, and analysis of variance was
participated in clinical dental examinations. The used to examine the associations using the DAS scale
weighted response rate for adults was 70% for the as a continuous score (representing the ‘severity’ of
interview and 84% for the dental examination (of dental anxiety). After examining the sociodemo-
those who participated in the interview). Because the graphic associations of dental anxiety (that is, the
2009 survey used the sampling frame from the 2006/07 DAS score continuous variable) at the bivariate level,
NZHS (that had an adult response rate of 68%), its we modelled its prevalence using negative binomial
effective response rate was 49% for the interview and regression. We then examined the clinical and dental
41% for the examination, but there was no evidence of service-use consequences of dental anxiety within
any non-response bias in respect of the oral health vari- three key age groups (18–34 years, 35–54 years and
ables collected in the 2006/07 NZHS17. 55+ years). All estimates are presented with 95% CIs.
Computer-assisted face-to-face interviews and den-
tal examinations were conducted. Interviews included
RESULTS
questions about oral health status, risk and protective
factors and the utilisation of oral health services. Den- Analyses in this paper are limited to the 2,209 adult
tal anxiety was measured using Corah’s Dental Anxi- New Zealanders (aged 18 years or older) who under-
ety Scale (DAS)10, which seeks responses to four went the clinical dental examination.
questionnaire items, which are then scored from 1 Table 1 summarises the prevalence of dental anxi-
(least anxious) to 5 (most anxious). A scale score of ety by sociodemographic characteristics. Overall, just
13 or higher is considered dentally anxious. The 14- over one in eight New Zealanders were dentally anx-
item Oral Health Impact Profile (OHIP-14)18 was ious. Dental anxiety was more prevalent among
used as a measure of OHRQoL. Neighbourhood females, 35- to 54-year-olds, non-M
aori and non-Paci-
deprivation was categorised using the New Zealand fic people, those educated to secondary school level,
Index of Deprivation 2006 (NZDep2006)19; partici- and those residing in the most deprived areas. Individ-
pants were allocated to a deprivation quintile from 1 uals in the lowest deprivation quintile were more den-
(least deprived) to 5 (most deprived). tally anxious than those in the most deprived quintile.
Information on oral disease (particularly dental Mean DAS scores were higher in females, 18- to 54-
decay and periodontal disease) was recorded during year-olds and in non-M
aori and non-Pacific peoples.
2 © 2020 FDI World Dental Federation
 Dental anxiety in New Zealand

Table 1 Dental anxiety prevalence and mean DAS Table 2 Negative binomial regression model for the
scores, by sociodemographic characteristics (brackets DAS score
contain 95% CI)
IRR* (95% CI) P value
Population Dental anxiety †
Female 1.14 (1.08, 1.21) <0.001
proportion
Prevalence Mean DAS Age group‡
35–54 0.99 (0.92, 1.07) 0.882
Sex 55+ 0.88 (0.81, 0.95) 0.002
Male 47.8 (46.9, 48.7) 9.8 (7.2, 13.3)* 7.8 (7.5, 8.1)* Ethnicity
Female 52.2 (51.3, 53.1) 16.5 (13.7, 19.9) 8.9 (8.6, 9.2) European/other 1.10 (1.04, 1.16) <0.001
Age group M
aori 0.96 (0.91, 1.02) 0.233
18–34 30.0 (28.6, 31.4) 16.1 (11.7, 21.8) 8.6 (8.1, 9.2)* Pasifika 0.95 (0.86, 1.04) 0.223
35–54 42.6 (40.8, 44.5) 13.8 (10.7, 17.6) 8.6 (8.3, 9.0) Deprivation quintile§
55+ 27.4 (26.1, 28.7) 9.5 (7.0, 12.9) 7.7 (7.3, 8.0) Second 1.01 (0.93, 1.10) 0.792
Ethnicity Third 1.01 (0.94, 1.09) 0.798
M
aori 11.1 (10.7, 11.5) 12.8 (10.2, 16.0) 8.2 (7.9, 8.6) Fourth 1.02 (0.94, 1.10) 0.649
Pacific 5.3 (5.1, 5.5) 12.4 (6.9, 21.1) 8.0 (7.3, 8.6) Highest 1.10 (1.00, 1.20) 0.049
Other 82.1 (79.9, 84.1) 14.3 (11.9, 17.0)* 8.5 (8.2, 8.7)*
Education level *Incidence rate ratio.
†
Primary 9.7 (8.3, 11.4) 13.2 (8.4, 20.2) 8.2 (7.7, 8.8) Reference category = Male.
‡
Secondary 68.6 (66.1, 71.0) 13.4 (11.2, 15.8) 8.3 (8.1, 8.6) Reference category = 18–34 years.
§
University 21.7 (19.4, 24.2) 13.3 (9.2, 18.7) 8.6 (8.2, 9.0) Reference category = Least deprived quintile.
Deprivation quintile
Lowest 21.2 (19.4, 23.1) 11.5 (7.8, 16.7) 8.2 (7.7, 8.7)*
Second 21.9 (20.1, 23.9) 13.2 (9.0, 19.0) 8.3 (7.8, 8.8) Table 3 Dental caries experience and periodontal
Third 19.2 (17.4, 21.2) 13.2 (9.0, 19.0) 8.3 (7.9, 8.8) status by dental anxiety category and age group
Fourth 20.2 (18.4, 22.0) 12.8 (9.1, 17.9) 8.3 (7.8, 8.7)
Highest 17.5 (16.0, 19.2) 16.4 (11.6, 22.7) 8.8 (8.3, 9.4) Not anxious Anxious
All combined 100.0 (–) 13.3 (11.4, 15.6) 8.4 (8.2, 8.6)
18–34 years
*P < 0.05. Mean coronal DT 1.0 (0.7, 1.18) 1.6 (0.5, 2.8)
Mean MT 0.6 (0.4, 0.8) 0.8 (0.2, 1.3)
Mean coronal FT 3.7 (3.1, 4.2) 4.2 (3.0, 5.3)
There was also a gradient by deprivation level, Mean coronal DMFT 5.3 (4.5, 6.0) 6.6 (4.8, 8.3)
whereby mean DAS scores were highest among those % with 1+ missing teeth 23.3 (17.8, 29.9) 23.9 (12.4, 41.1)
% with 3+ missing teeth 9.2 (6.0, 13.9) 13.5 (5.6, 29.2)
who resided in the most deprived areas. % with 1+ sites with 0.1 (0.0, 0.1) 0.0 (0.0, 0.0)*
Table 2 presents the outcome of the multivariate 6 mm AL
model for the DAS score. On average, DAS scores 35–54 years
Mean coronal DT 0.8 (0.6, 0.9) 1.2 (0.8, 1.6)*
were higher by 14% among females, lower among Mean MT 3.5 (3.1, 3.9) 5.0 (3.8, 6.2)
those in the oldest age group (55+), higher by 10% Mean coronal FT 9.3 (8.7, 9.9) 9.6 (8.1, 11.0)
among those in the European/Other ethnic category, Mean coronal DMFT 13.6 (12.9, 14.2) 15.8 (14.3, 17.3*
% with 1+ missing teeth 63.6 (59.1, 67.8) 76.0 (66.0, 83.7)*
and higher by 10% among those residing in the most % with 3+ missing teeth 47.9 (43.5, 52.4) 60.4 (48.0, 71.6)
deprived neighbourhoods. % with 1+ sites with 12.3 (9.8, 15.2) 14.2 (7.4, 25.5)
Data on dental caries experience and periodontal 6 mm AL
55+ years
status are presented by dental anxiety status in Mean coronal DT 0.6 (0.4, 0.7) 0.8 (0.4, 1.2)
Table 3. With the exception of mean coronal FT and Mean MT 10.1 (9.4, 10.9) 11.4 (8.2, 14.6)
DMFT in those aged 55 or more, those who were Mean coronal FT 12.5 (11.7, 13.2) 10.1 (7.7, 12.6)
Mean coronal DMFT 23.1 (22.6, 23.7) 22.4 (20.5, 24.3)
dentally anxious had greater disease experience. % with 1+ missing teeth 98.4 (96.5, 99.3) 99.3 (94.7, 99.9)
Table 4 presents data on dental attendance patterns % with 3+ missing teeth 90.9 (87.7, 93.4) 86.2 (57.1, 96.7)
by dental anxiety. Dentally anxious individuals were % with 1+ sites with 19.0 (14.9, 24.1) 28.6 (18.0, 42.1)
6 mm AL
less likely to have visited the dentist within the previous
12 months. With the exception of those in the 18–34 *P < 0.05.
age group, a higher proportion of dentally anxious
individuals were episodic visitors. People aged 35 years older, they were 13.3% (95% CI = 10.2, 17.1) and
or older were more likely to be episodic visitors. 15.5% (95% CI = 7.0, 31.2), respectively. The highest
The prevalence of OHIP-14 impacts was greater prevalence of OHIP-14 impacts was observed in den-
among those who were dentally anxious. Among 18- tally anxious 35- to 54-year-olds.
to 34-year-olds, it was 15.8% (95% CI = 10.8, 22.5)
and 17.8% (95% CI = 8.4, 33.7), respectively, in den-
DISCUSSION
tally anxious individuals and those who were not.
Among 35- to 54-year-olds, those estimates were This investigation of the prevalence of dental anxiety
15.6% (95% CI = 12.5, 19.3) and 30.5% (95% CI = among New Zealand adults has found that 13.3% are
20.2, 43.2), respectively; in those aged 55 years or affected, and the condition is more common among
© 2020 FDI World Dental Federation 3
Sukumaran et al.

Table 4 Dental attendance patterns in dentally and non-dentally anxious New Zealanders, by age group
Not anxious Anxious Both

18–34 years
Episodic visitor 58.3 (49.9, 66.2) 58.1 (43.6, 71.3) 58.3 (50.9, 65.2)
Within previous year* 43.4 (36.7, 50.4) 33.1 (20.3, 48.9) 41.7 (35.3, 48.4)
35–54 years
Episodic visitor 61.1 (56.5, 65.6) 77.2 (66.0, 85.6) 63.3 (59.1, 67.4)
Within previous year* 52.4 (47.8, 57.0) 43.2 (31.2, 56.0) 51.1 (47.2, 55.1)
55+ years
Episodic visitor 47.4 (42.3, 52.5) 61.4 (41.8, 77.9) 48.7 (43.7, 53.8)
Within previous year* 64.6 (58.8, 69.9)† 36.2 (21.8, 53.7)† 61.9 (56.6, 66.9)
All ages
Episodic visitor 56.4 (52.8, 60.0) 67.2 (59.2, 74.3) 57.8 (54.6, 61.0)
Within previous year* 53.3 (49.8, 56.7) 38.2 (30.0, 47.1)† 51.3 (48.0, 54.5)

*Dental visit made during the previous year.

†
P < 0.05.

females, highly deprived groups, 18- to 54-year-olds, investigate associations between dental anxiety and
and non-M
aori and non-Pacific peoples. Dentally anx- OHRQoL in New Zealand.
ious individuals also had greater disease experience, The 13.3% population prevalence estimate for
with the exception of mean coronal FT and DMFT in dental anxiety is a little lower than those from stud-
those aged 55 or more. With the exception of 18- to ies of subnational samples in New Zealand that
34-year-olds, dentally anxious individuals were more have used the DAS. For example, the prevalence of
likely to be episodic visitors and less likely to have dental anxiety observed in the West Coast region of
sought dental care during the previous 12 months. New Zealand’s South Island was 20.8%16. The
Furthermore, those who were dentally anxious had Dunedin Multidisciplinary Health and Development
higher OHRQoL scores, on average. Study observed a prevalence rate of 21.1% among
Before considering the findings, it is important to 26-year-olds, and 18.4% for the same cohort by the
acknowledge the limitations of this study. The cross- age of 32 years12. A more recent cross-sectional sur-
sectional design of the 2009 NZOHS means that the vey of a representative sample of the Dunedin adult
time ordering of the observed associations between population found the prevalence of dental anxiety to
dental anxiety and oral health, dental attendance pat- be 18.6%9. It should be noted, though, that all of
terns and OHRQoL remains unclear. However, the those estimates for younger adults fall within the
time ordering of similar associations observed in the confidence interval for the prevalence estimate for
longitudinal Dunedin Multidisciplinary Health and the 18- to 34-year-old age group in the current
Development Study was able to be clarified12, and study, suggesting that our overall estimate is not
those are likely to hold here. Data on dental anxiety atypical.
were collected using Corah’s DAS. This scale has a That DAS scores were higher among females and
number of limitations, including no clear conceptual younger people is consistent with the Australasian and
basis and non-mutually exclusive response categories5. international literature. It is noteworthy, however,
However, moderate-to-high correlations have been that those living in the most deprived neighbourhoods
identified between scores on the IDAF-4C and the had higher DAS scores, on average. They are also the
DAS in a New Zealand population9, supporting asser- group with less favourable utilisation of dental ser-
tions about the scale’s likely validity and bolstering vices and higher rates of the common oral condi-
the accuracy of the current study’s estimates for den- tions15. Efforts to reduce inequities in dental service-
tal anxiety. To date, the DAS and the MDAS remain use and inequalities in oral health will need to also
the most widely used measures for recording dental consider ways of alleviating the burden of dental anxi-
anxiety. The study data are also somewhat dated, but ety among vulnerable groups.
they remain the most recent generalisable estimates Looking globally, our prevalence estimate is similar
for the New Zealand population; the delay in report- to those from other developed countries, such as France
ing is due to funding constraints (we are conducting (13.5%) and Australia (14.9%), but higher than in
such secondary analyses without funding). Despite Sweden (9.2%) and Denmark (10.2%), and lower than
these limitations, this study has some strengths. Its in Germany (17%)1,3,6–8. An almost universal finding
large and representative sample, comprehensive clini- in the dental anxiety literature—also confirmed in our
cal data and use of a gold-standard OHRQoL mea- study—has been the greater prevalence of dental fear
sure mean that it was well placed to examine the among women and younger individuals, and that dental
prevalence and associations of dental anxiety among anxiety is associated with episodic dental atten-
New Zealanders15. It is also the first study to dance9,12. Studies in other countries also found that
4 © 2020 FDI World Dental Federation
 Dental anxiety in New Zealand

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© 2020 FDI World Dental Federation 5