GENERAL DENTISTRY

Recognizing and differentiating dental anxiety from

dental phobia in adults: a systematic review based on the
German guideline “Dental anxiety in adults”
Sebastian Bürklein, Prof Dr med dent/Christoph Brodowski/Eva Fliegel/
Hans Peter Jöhren*, Prof Dr med dent/Norbert Enkling*, Prof Dr med dent

Objectives: The prevalence of “dental anxiety” (DA) is often un- methods and tools used in the 51 reviewed articles to assess
derestimated and numerous diagnostic methods are available DA levels were evaluated in terms of their practicability and
for dental practitioners. It is difficult to differentiate between a suitability in daily practice to differentiate between phobia (ie,
dental phobia requiring an interdisciplinary approach and DA, DA disorder) and nonpathologic anxiety. In addition, the inter-
which can be managed by dental practitioners alone. The ap- nal consistency (Cronbach alpha) of the questionnaires/tools
propriate use of diagnostic tools is key for the successful man- was determined. Conclusion: All identified DA questionnaires
agement of highly anxious and/or phobic patients. The aim was validated in the German language had an acceptable to excel-
to provide a guideline to recognize dental fear and to differen- lent internal consistency (0.7 to 0.986). The only validated ques-
tiate DA from patients who are highly anxious or even have a tionnaire-free method was galvanic skin reaction measure-
phobia. Data sources: In total, 8,929 articles that were selected ment. For the assessment of DA and diagnosis of a DA disorder
for the development of the German guidelines for “Dental anx- in adults, the survey by means of any suitable questionnaire or
iety in adults” in PubMed, Web of Science, Embase, and Med- even several questionnaires in combination with a behavioral
Pilot were filtered for diagnosis of DA disorder. The focus for observation of the patient is currently the method of choice.
this review was on the use of scales to measure DA levels. The (Quintessence Int 2021;52:360–373; doi: 10.3290/j.qi.a45603)

Key words: dental anxiety, dental phobia, diagnosis, probability, scale

Dental anxiety (DA) and its impact on oral health is a widely patients have poorer oral hygiene compared to nonanxious
underrated subject in dentistry. The reported prevalence of DA patients in general.11 Eventually, dental anxiety may have a
is highly variable and ranges from 5.7% to over 40%, and affects negative impact on social interactions and lead to a decline in
approximately one third of dental hygiene recall patients.1-5 quality of life, caused by embarrassment and feelings of shame
Moreover, patients suffering from DA are more likely to cancel or guilt when eating, smiling, and talking.12
dental appointments in the first place.6 Hence, DA is a common Historically, DA has been attributed to the expectation of pain,
problem experienced in dental practice. and the etiology of DA features classic characteristics of condition-
As oral health is linked to a multitude of inflammatory and ing, originating in early periods of life (childhood to early adoles-
systemic diseases, it can be considered fundamental to overall cence).13-16 Nevertheless, an individual’s dental fear/phobia is likely
physical and mental wellbeing.7 DA, however, leads to an to have its origin in a multitude of factors like genetic vulnerability,
increased caries prevalence and incidence in adults and conse- negative affectivity/anxiety vulnerability, preparedness, cognitive
quently results in a poor dental health status among anxious conditioning (Pavlovian), operant conditioning, vicarious experi-
patients due to avoidance.8-10 Additionally, highly anxious ence and verbal threat, cognitive content, or cognitive biases.17

360 QUINTESSENCE INTERNATIONAL | volume 52 • number 4 • April 2021

 Bürklein et al

Exploring DA in the population should be of special interest signs of anxiety (vegetative and general symptoms) and typical
as DA is considered by many patients, and also by dental prac- anxiety behavior (eg, avoiding eye contact, hesitant answers,
titioners, to be an unavoidable evil. The real level of DA is usually fright reactions).26
unknown when starting the treatment. Furthermore, in dental Differentiation between highly anxious patients and
practice, a diagnostic differentiation between DA and dental patients exhibiting a DAD is of great importance and must be
phobia is usually difficult to achieve. This is aggravated by the carefully assessed. This subjective level includes the anxiety
fact that there is a lack of uniformity in the use and definition of experienced by the affected individual: apprehension, feelings
the different terms: “fear,” “anxiety,” “high anxiety,” and “phobia.” of helplessness, the feeling of being at the dental practitioner’s
Additionally, in contrast to other anxiety disorders, the at- mercy, thought patterns generated by anxiety, and therefore
tending dental practitioner is usually the first contact and initi- the associated subjective anxiety experience (“something bad
ates the diagnostic process for patients with DA, DA disorder is going to happen”).23 Even the imagination of past or future
(DAD), or phobia. Understandably, dental practitioners often in anxiety-inducing situations or the perception of a stimulus as
turn exhibit and display greater stress reactions when treating potentially dangerous can lead to physical reactions or specific
patients with high levels of fear or anxiety disorders.18,19 The behavioral patterns.16,17
dental treatment of anxious patients is characterized by time- The pathologic dental treatment anxiety represents a pho-
consuming procedures, difficult interactions in combination bic disorder (ICD-10 F40.0) which is defined as an immediate,
with a higher risk of accidents, the feeling of inadequacy on the inappropriate fear reaction to a clearly defined situation.27
dental practitioners’ part, and higher costs due to frequently Among the phobic disorders, dental treatment phobia belongs
missed appointments.18,19 For this reason, a previous knowledge to the isolated specific phobias (ICD-10 F40.2; DSM 300.29).27,28
of the extent of the anxiety as evaluated in the anamnesis in Fear or anxiety usually results in the expression of a range of
addition to the somatic disorders may guarantee an adequate adaptive or defensive behaviors, aiming to escape from the
and significantly less stressful treatment of the anxious patient source of danger or the triggering conflict. The defensive sys-
and may provide more favorable outcome of dental treatment.20 tem with its hyper-responsiveness is claimed to be the key psy-
Because anxiety is a cognitive, emotional, and physical chopathologic process on a neurophysiologic level related to
reaction to an existing or expected dangerous and threatening specific phobias. The triggering event leads to a characteristic
situation, the patient’s anxiety response spans three dimen- pattern of response, varying according to the perceived threat
sions: the physiologic, the subjective, and the motoric or level and the strength of the accompanying arousal of the
behavioral levels.21 For this reason, anxiety can be diagnosed at defensive system. Two kinds of mechanism occur: i) defensive
all three of these levels in terms of the complex response pat- immobility and ii) defensive action. The reaction is initially
tern. The most reliable method for determining the level of accompanied a by a decrease of the heart rate and an inhibi-
anxiety before dental treatment in everyday dentistry is to tion of defensive reflexes such as the startle response.29,30 When
interview the patients affected.22 An observation of heart rate excitement increases, the defensive reflexes are eased. Due to
and/or electrodermal activity (EDA) (ie, galvanic skin response the sympathetic activation, the heart rate switches from decel-
[GSR]) may provide subjective add-on information of a patient’s eration to acceleration representing a shift from defensive
state but needs additional technical equipment.23 For optimal immobility to action (fight and flight reaction).
outcomes, it is necessary to determine in advance whether the However, the extent to which dental phobic reactions also
patient will be able to bear the dental treatment or if an inter- include vasovagal responses that are frequently observed in
disciplinary approach is required, such as a referral to experts in phobias associated with fear of blood, injections, and injuries
the field of psychology, eg a psychologist or psychiatrist. In this (BII), is controversially discussed. Occurrence of comorbidities
way, a proper psychologic diagnosis is assured and a decision in dental anxious patients varies between 13% and 55%.31-33
on the options for further treatment can be offered, in consid- The BII-phobia is typically associated with a diphasic cardiovas-
eration of the fact that comorbidities are frequently present in cular response of an initial tachycardia, followed by bradycar-
anxious patients.24,25 In some cases, the psychologist and the dia, hypotension, shock, vertigo, syncope, diaphoresis, nausea,
dental practitioner need to work together. It is therefore incum- and seldom asystole and death.34
bent on dental practitioners to confirm suspicions of the pres- In most of the cases, the BII-phobia response is character-
ence of an anxiety disorder by asking specific questions and ized by syncope or presyncope – meaning, BII-phobia patients
observing the patient’s behavior including both the physical are more prone to fainting when being confronted by the stim-

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 GENERAL DENTISTRY

Fig 1 PRISMA diagram showing the flow-

Records identified chart of systematic identification, screening,
Dental anxiety OR Dental anxious
inclusion, and exclusions of records
PubMed (22 Oct 2015) 5,751 records
OR Dental phobia OR Dental identified.
ISI Web of Science (22 Oct 2015) 2,388 records
Identification

phobics OR Dentophobia OR
OVID SP (Embase) (22 Oct 2015) 457 records Dental fear OR Oral phobia

Zahnarztangst OR Zahnarztphobie
Livivo (24 Oct 2015) 333 records OR Zahnbehandlungsphobie OR
Zahnbehandlungsangst OR
Total 8,929 records Oralphobie OR Dentalphobie

5,770 titles after elimination of 5,019 exclusions after screening titles

duplicates according to the exclusion criteria:
– Participants under 16 years
– Case studies
– Double publications
Screening

– Reviews

751 titles based on the abstracts for 383 exclusions after examination of the
examination (6 Nov 2015) abstracts based on the exclusion criteria:
– Subjects under 16 years of age
– Case studies
– Reviews

368 titles based on the full texts for 135 exclusions after reading the full
examination: texts based on the exclusion criteria:

182* titles on etiology and prevalence – 13 Reviews

67* titles on diagnostics – 3 Case reports/ case studies
Eligibility

192* titles on the subject of – 100 Serious deficiencies in study design

therapy/aftercare / study implementation / study
evaluation
*Some titles were assigned to more
than one chapter – 10 Unsuitable group of test persons
– 7 No study on dental fear
– 2 Double publications

20* titles included in the evidence

assessment on therapy
80* titles on etiology and prevalence
51* titles related to diagnostics
Included

90* titles on the subject of therapy /

aftercare
*Some titles were assigned to more
than one chapter

­ Total literature titles used 233

1

ulus.35 This behavior usually is not observed in dental phobic – represents an adjunct to the treatment of adult patients
patients.36 Hence, practitioners should be aware of the under- attending general practice and does not negatively influence
lying reasons for the anxiety and decide if it is possible to lead the state and trait anxiety.38
the patient through the treatment. Nevertheless, the comparison of validated questionnaires
In general, systematic and comparative research into DA with regard to quality is almost impossible, since different
started with the development of standardized questionnaires.37 objectives are pursued. The aim of the review of the literature,
It should be taken into account that a normal assessment of DA compiled for the evidence based German Guideline “Dental
prior to treatment – meaning completion of a DA questionnaire anxiety in adults”,39 was:

362 QUINTESSENCE INTERNATIONAL | volume 52 • number 4 • April 2021

 Bürklein et al

■ To evaluate the existing questionnaires with regard to their – DSM-IV 28 300.29 (F40.23x) BII (eg, needles, invasive
practicability in everyday dental practice. medical procedures
■ To check whether they are suited to differentiate between – ICD-1027 F40.2 Specific (isolated) phobia
anxiety and a dental anxiety disorder/ phobia. – Definition of a cut-off score for high anxiety (question-
■ To compare the psychometric instruments using Cronbach naire for DA; eg, Dental Anxiety Score (DAS) > 15)3-
alpha. – Studies involving patients with “unspecified dental fear/
anxiety” but who did not meet the criteria for dental
This systematic review was intended to help clinicians to select phobia (ie, moderately anxious patients) or who did not
a suitable questionnaire or screening tool that provides the have a homogenous highly anxious sample based on an
desired information and in particular differentiates between anxiety scale were also included.
fear of being treated and phobia. Hence, the null hypothesis
was that all questionnaires or screening tools are equally suited ■ Randomized controlled trials (RCTs)
in recognizing dental fear and differentiate between subclinical – Studies comparing interventions with control group
and pathologic forms of dental fear. (placebo, psychologic placebo, waiting list)

■ Studies comparing interventions with reference therapy. The

Methods and materials
reference therapy was defined as a therapy that has been
shown to be effective in preliminary studies compared to a
Data sources
control group.
For the systematic literature review to draft the German Guide- ■ Naturalistic open studies with comparison before and after
line “Dental anxiety in adults” that was published in October intervention
2019,39 the following keywords were defined: “dental anxiety,” ■ Sample size: at least 10 evaluable patients per group (for a
“dental anxious,” “dental phobia,” “dental phobics,” “dentopho- noninferiority comparison, a minimum of 50 evaluable pa-
bia,” “dental fear,” “oral phobia.” tients per study arm was required)
The terms for the guideline and the present study were ■ Adults
linked with “AND” or “OR” and the search was conducted for ■ Use of scales that measure DA (eg, DAS) or state anxiety in
articles published until 22 October 2015 without further date situations directly related to the dental treatment or the
restrictions. The only requirement for inclusion was the avail- visit to the dental practitioner (eg, State-Trait
- Anxiety Inven-
ability of an abstract written in English or German language. tory-State or Visual Analog Scale [VAS] to assess the inten-
The literature search for the guideline was carried out in the sity of anxiety during dental treatment):40,4
databases PubMed, Web of Science (Core collection), and – Studies whose results contribute to answering at least
Embase. Two reviewers (CB, EF) carried out the electronic litera- one of the abovementioned guideline questions
ture search using the literature administration program Endnote – Match of quality criteria: For this purpose, a systematic
(Web of Science Group). The electronic search was comple- approach was used, which is also found in the World
mented by manually browsing the bibliographies of the selected Federation of Societies of Biological Psychiatry (WFSBP)
full texts, other systematic reviews, and current meta-analyses. guidelines.42
In addition, publications in German language were searched
with the help of MedPilot using the terms Zahnarztangst
t t (dental
Exclusion criteria:
fear), Zahnbehandlungsangstt (dental treatment fear), Zahn-
behandlungsphobie (dental treatment phobia), Zahnarztphobie ■ Reviews and case reports
(dentist phobia), and Oralphobie (oral phobia = generic term for ■ Insufficient study quality:
all phobias related to the oral cavity). – lack of information on the result
– lack of information on statistical parameter
– insufficient statistical evaluation
Inclusion criteria
– studies in which one or more study groups contained
■ Studies were included with patients who had “dental anxiety less than 10 evaluable subjects:
disorder or high dental fear.” These included:

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 GENERAL DENTISTRY

■ Studies with unsuitable groups of subjects completely spelled out OR as an “abbreviation” AND “dental
– studies with children and/or adolescent anxiety” AND/OR “dental phobia” (Table 2).
– studies with subgroups only (seniors/etc).

■ Studies not related to dental fear/anxiety.

Review

Dental Anxiety Scale (DAS)

All titles found were inspected and thematically relevant titles
were subsequently subjected to an abstract screening. Any dis- The most frequently used anxiety scale in dentistry is the DAS
agreements among the reviewers regarding article selection according to Corah.37 It consists of four questions with five pos-
were clarified by discussion until agreement was reached. sible answers each. The patient is asked to choose between
A total of 8,929 titles were identified. After removing the different situations and tick the answer option that corre-
duplicates, these were reduced to 5,770, and after evaluation of sponds to his/her current state and the perception, in relation
the headings, 751 abstracts were rated eligible regarding the to the respective situation. The scoring of each question ranges
following items: review/RCT/prevalence/therapy/diagnostics/ from 4 to 20. According to Corah,37 values less than 9 are
epidemiology/comorbidity/prevention/meta-analysis/general nonanxious and values between 9 and 12 indicate moderate
or full anesthesia. anxiety that can likely be managed. High anxiety is indicated by
The guideline members had the opportunity to reinclude values of 13 and 14. The next level is 15 to 20, meaning severe
literature that had been initially rejected until 23 April 2016. anxiety and representing a possibly phobic stage of fear.81 The
This was done with regard to 17 items. Finally, after reading all stability of the DAS is very high.48-50 The DAS was translated into
preselected full-texts, 20 titles were included in the evidence German by Tönnies et al51 and examined in the German version.
evaluation for therapy, 80 titles on etiology and prevalence, 51
titles related to diagnostics, and 90 titles on the subject of ther-
Modified Dental Anxiety Scale (MDAS)
apy and aftercare – resulting in a total of 233 titles (titles could
be assigned to multiple categories) (Fig 1). Since the DAS does not include questions about local anesthesia,
Due to extensive controversy discussions during the con- which is claimed to be a significant factor in many patients’ dental
sensus process by all affiliated scientific societies of the Ger- anxiety, the Modified Dental Anxiety Scale (MDAS) was devel-
man guideline of “Dental anxiety disorder in adults” (end of oped.52,59 The MDAS includes a question concerning local anes-
2015 to 2019), in the context of the current review, a second thesia and therefore has a point distribution of 5 to 25. In addition,
literature research was conducted with identical keywords for the other questions have been modified and now relate to pure
the diagnosis of dental anxiety/phobia including the current anxiety perceptions and not to possible feelings. Due to the mod-
literature until 1 April 2020. Ten relevant references were addi- ification, the cut-off point for the presence of a phobia is ≥ 19.61,62
tionally included.5,6, 14,23,36,43-47 This review focused on the DA
questionnaires validated in the German language. They vary to
State-Trait Anxiety-Depression Inventory (STADI)
a large extent in their ability to recognize anxiety and to differ-
entiate between high anxiety and suspected DAD (Table 1). The State-Trait
- Anxiety-Depression Inventory (STADI)82 ques-
The correlation to the DAS, the oldest and most commonly tionnaire is based on Spielberger’s theory of fear and does not
used questionnaire in studies on DA, and internal consisten- specifically refer to dental fear, but rather on anxiety in a variety
cies were extracted from the included articles. Overall, all of daily situations. It consists of two modules: The trait anxiety
questionnaires showed an acceptable (Cronbach alpha > 0.7) captures anxiety as a superordinate property independent of
to excellent reliability (> 0.9) and the correlation to the DAS (as the time and situation of the survey. The state anxiety measures
far as determined) was above r = 0.7 for all questionnaires. the anxiety at a defined moment and in a specific situation. This
In order to make the acceptance and distribution of the can be an advantage in practical investigations as many pa-
questionnaires and screening tools used transparent for the tients do not feel any fear during the dental hygiene appoint-
reader, the literature search was extended to evaluate the total ments, but do feel fear of any restorative and more invasive
number of uses of the screening tools and questionnaires. The procedures. The questionnaire distinguishes anxiety from de-
following databases and keywords were used: PubMed, Web of pression symptoms that are often associated with DA. They
Science, Embase, and MedPilot: “Questionnaire/screening tool” must be distinguished for an accurate diagnosis.

364 QUINTESSENCE INTERNATIONAL | volume 52 • number 4 • April 2021

 Bürklein et al

In dental research, STADI has replaced the STAI according to to capture anxiety disposition by three different components
Spielberger.40 This index has been frequently used in the past. of the anxiety/fear of dental treatment:
It has to be borne in mind that there is no direct association ■ time (at home, the way to the dental practitioner, the wait-
between the state anxiety and the trait anxiety.66 The correla- ing time, and the time in the dental chair)
tion of the trait scale of the STAI to the DAS is r = 0.76.40 ■ situation (introductory aspects, dental practitioner-patient
interaction, current pending dental treatment)
■ reaction (subjective sensations, physical reactions, and the
Dental Fear Survey (DFS)
cognitive level).
The Dental Fear Survey (DFS)67 questionnaire consists of 20
questions concerning the level of anxiety in different dental Much attention was given to the definition of anxiety in terms
situations. Each question can be answered in terms of a Likert of state versus trait anxiety and anxiety as a process.
scale of 1 to 5. Two items relate to avoidance behavior, five to
physiologic reactions, and 12 in hierarchical order to specific
Short version of the Dental Anxiety Inventory
stimuli that trigger anxiety during dental treatment. One
(S-DAI)
question aims for general assessment of the fear of dental
treatment. The score is between 20 (no fear) and 100 (great The short version of the DAI (S-DAI) developed by Aartman73
fear). One DFS question is also used to obtain more precise contains only nine questions from the DAI: three time-related
information about anxiety-inducing stimuli during dental questions (the way to the dental practitioner, waiting room,
treatment. The average score is 37, and a score of 60 or more and sitting on the treatment chair), three concrete dental situ-
may lead to suspected diagnosis of a “severe form of dental ations (noise of the drill, tooth extraction, and anesthesia), and
fear requiring treatment.”51,67 The DFS is therefore a suitable three questions about the reactions of the affected person
diagnostic measuring instrument for the presence of a dental (flight reflex, sweating, closing eyes).
phobia.67 This results in a correlation coefficient of r = 0.92 to A factor analysis revealed a moderate to good agreement/
the DAS.16,50,68 consistency of the individual questions to the whole question-
naire (0.6 minimum and 0.84 maximum). The correlation to DAS
is r = 0.73.73
Dental Belief Survey (DBS)
The Dental Belief Survey (DBS)63 is not primarily a test-psycho-
Dental Cognitions Questionnaire (DCQ)
logic method for recording fear of dental treatment, but rather
an instrument that measures the effect of the dental practi- The self-
f rating Dental Cognitions Questionnaire (DCQ) according
tioner on the patient. A revised version (Revised Dental Belief to de Jongh et al54 consists of 38 negative cognitions (beliefs and
Survey [DBS-R]) refers not only to the aspects of ethical back- self-
f statements) related to dental treatment. The patient is asked
ground, communication, and control, but also considers trust as to confirm if they occur during dental treatment.54 Fourteen
a further point.69,70 DBS results correlate strongly with dental items focus on negative beliefs pertaining to dentistry/dental
fear. Research shows that treated dental fear does not necessar- practitioners in general and to the patients themselves. The
ily change the attitude towards the dental practitioner (“belief”). remaining 24 items relate to negative self- f statements (eg,
The attitude itself therefore seems to play a fundamental role in “Everything is going wrong”). Patients are asked to indicate
the development of dental fear. It has been shown that an whether they notice these negative perceptions during dental
improved attitude towards the dental practitioner from the treatment. The questions are answered with “yes” or “no.” The
beginning, eg through dental consultations and measured by frequency of “yes” answers (score range 0 to 38) is summed
DBS, increased the success in treating dental fear.69,70 (DCQ frequency score).54 In addition, patients individually eval-
uate the likelihood of their conviction by making a self- f assess-
ment of their perceptions. People with dental phobia have a
Dental Anxiety Inventory (DAI)
significantly higher number of negative cognitions than non-
The Dental Anxiety Inventory (DAI) was developed by Stouthard phobic controls.54 The correlation between the frequency and
et al71,72 in 1993 and its high correlation to the DAS (r = 0.73) the believability scores revealed an acceptable level of validity
was demonstrated. It includes 36 questions, which are intended (r = 0.58) and the internal consistency for the DCQ-reliability

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 GENERAL DENTISTRY

Table 1 Questionnaires validated in German language

Question- No. of Scores per Max. Highly

naire questions question score anxious Special features/contents
DAS 1969 4 1–5 20 ≥ 13 Does not include questions about local anesthesia

MDAS 1985 5 1–5 25 ≥ 19 DAS supplemented by one item: “local anesthesia”

STADI 2013 2 × 20 = 40; 20 1–4 80 each ≥ 45 Two-part questionnaire: 1) general emotional state; 2) situation-
(previously: (State); 20 (Trait); related emotional state. Differentiation between anxiety and
STAI) separately or jointly depression
DFS 1973 20 1–5, level 5 = highest 100 > 60 Includes questions on: 1) Avoidance behavior; 2) Psychovegetative
fear, level 1 = lowest fear reactions to specific stimuli; 3) Fear/feelings in specific treatment
fear situations; 4) Final assessment (global anxiety disorder)
DBS 1985 15 1–5, 1 = highly 75 > 48 Weighing of the questions: Psychometry, Communication, Confidence,
positive belief, 5 = Disparagement, Loss of control
highly negative belief
DAI 1993 36 1–5 unimodal answer 180 Self-
f assessment: a) Situational aspects (general fear of dental
alternatives treatment (current treatment, interaction with the dental practitioner);
b) Time related aspects (at home, way to dental practitioner, waiting
room, chair); c) Reaction aspects (emotional, physical, cognitive)
S-DAI 1998 9 1–5 45 9 DAI items: anxiety-triggering situations; time-related situations;
reacting
DCQ 1995 38 Dichotomous index: 38 ≥ 19 38 negative findings (convictions and self-
f statements) in the context
yes or no of dental treatment. 14 items: Dentistry in general. 24 treatment-
related statements. Rating of the own conviction of perceptions by
a self-
f assessment
HAQ 1999 11 1–5 55 > 38 Also includes avoidance of appointments/visits to the dental
practitioner

SDFQ 1995 1 4 response options Answer 4 Answer 4 One question: quick evaluation

IDAF-4C+ 2010 23 1–5 5.0 ≥ 3.0 4 components of the dental anxiety: cognitive, physiologic, behavioral,
emotional

DAQ 1990 1 4 response options: Yes, very Yes, very One question: quick evaluation
no; a little; yes, quite;
yes, very
VAS 1 Free choice by the 100 ≥ 70 10-cm long scale, free choice by the patients
patients

and -believability were 0.89 and 0.95, respectively.54 The cor- most fear-inducing situations in treatment and offer five differ-
relation coefficient with DAS is r = 0.74.55 ent types of fear to reply (from “relaxed” [= 1 point] to “sick of
anxiety” [= 5 points]). The sum of the scores allows division of
patients into three groups: low anxious or slightly anxious (≤ 30
Hierarchical Anxiety Questionnaire (HAQ)
points), moderately anxious (31 to 38 points), and extremely
The Hierarchical Anxiety Questionnaire (HAQ),74 based on the anxious (possibly phobic) (> 38 points). The HAQ allows a sus-
DAS according to Corah,37 includes 11 questions related to dif-
f pected diagnosis of a dental phobia when the score exceeds
ferent dental treatment situations that are presented in a hier- 38 combined with a simultaneous anamnestic avoidance of
archically structured sequence.83 The questions focus on the dental treatment over more than 2 years.44,75,76 The question-

366 QUINTESSENCE INTERNATIONAL | volume 52 • number 4 • April 2021

 Bürklein et al

Differentiation between fear Crohnbach

Evaluation and phobia alpha* References
No: only low, medium, and high Up to 0.84 Jaakkola et al,4 Kruger et al,8 Eitner et al,9 Nermo et al,14 Sartory
anxious; 13–14 highly anxious; 15–20 anxiety et al,26 Corah,37 Naumova et al,45 Talo Yildirim et al,46 Locker and
extremely anxious/ phobia Liddell,48 Moore et al,49 Johansson and Berggren,50 Tönnies
et al,51 Humphris et al,52 Moore et al,53 de Jongh et al,54 Sartory
et al,55 Neverlien,56 Luuk et al,57 Schuurs et al58
< 11 not anxious; ≥ 11 slightly anxious; No: anxious, moderately anxious, Up to 0.83 White et al,6 Appukuttan et al,41 Höglund et al,43 Humphris et
11–14 moderate anxious; 15–18 very highly anxious, and extremely al,52,59 Humphris and Hull,60 Pekkan et al,61 Viinikangas et al,62
anxious; ≥ 19 extremely anxious anxious Milgrom et al,63 Kanegane et al,64 Armfield et al65
≤ 22 low; 23–31; 32–40; 41–49; No Up to 0.9 Hofer et al,5 Wang et al,20 Naumova et al,45 Talo Yildirim et al,46
≥ 50 Moore et al,53 de Jongh et al,54 Sartory et al,55 Luuk et al,57
Humphris and Hull60
Very anxious > 60; phobia > 75 Yes, phobia = DFS score over 65 0.95 Johansson and Berggren,50 Wardle,66 Kleinknecht et al,67
AND avoidance Moore et al,53 Berggren et al68

Not anxious, little anxious, moderately No Up to 0.91 Berggren et al,68 Milgrom et al,63 Abrahamsson et al69,70
anxious, highly anxious, extremely
anxious
36 = no anxiety; 180 = high anxiety No Up to 0.75 Stouthard et al71,72

No standard data/cut-off values No Up to 0.88 Aartman73

available
Items are summarized to get a total Phobic patients = score ≥ 19 Frequency 0.89, de Jongh et al,54 Sartory et al55
value for negative perceptions. Rating believability
of the own conviction of perceptions by 0.95
a self-
f assessment.
< 30 low level of anxiety; 31–38 Yes: phobia = HAF > 38 and Up to 0.936 Enkling et al,2 Hofer et al,5 Lenk et al,25 Sartory et al,26
medium level of anxiety; > 38 high level avoidance > 2 y Wannemueller et al,36,44 Sartory et al,55 Jöhren,74 Jöhren et al,75
of anxiety; phobia = HAF > 38 and Jöhren and Sartory,76 Barthelmes77
avoidance > 2 y
1 = relaxed; 2 = slightly anxious; 3 = No Up to 0.89 Jaakkola et al4
moderately anxious; 4 = extremely
anxious
3 modules: Base module IDAF-4C Yes, special phobia module based Up to 0.94 Wang et al,20 Armfield,78 Tönnies et al79
(8 items); Phobia module IDAF-P on DSM-IV diagnostic criteria;
(5 items); Stimulus module IDAF-S IDAF-4C ≥ 3.0 and interferences
(10 items) with life or distress
No, little, anxious, very anxious No Up to 0.88 Neverlien56

0 = not at all; ≥ 48 and (Yes) Up to 0.968 Hofer et al,5 Appukuttan et al,41 Höglund et al,43 Luuk et al,57
< 70 anxious; ≥ 70 (phobia) Kanegane et al,64 Barthelmes,77 Facco et al80

naire was validated and checked for its reliability (0.936) and Consisting of three modules, each with eight items, the IDAF-4C+
its internal consistency (0.94).74 The correlation to DAS is analyses emotional, behavioral, physiologic, and cognitive
r = 0.88.74 responses related to dental fear. Each module uses a Likert scale
ranging from 1 to 5 (1 = strongly disagree, 5 = strongly agree).78
In the first, general module “IDAF-4C,” emotional and cogni-
Index of Dental Anxiety and Fear (IDAF-4C+)
tive aspects, behavioral observations, and physiologic reac-
The Index of Dental Anxiety and Fear (IDAF-4C+)78 consists of tions were recorded. In the IDAF-P module, the presence of a
three modules designed to measure both fear and phobia. The phobia is checked based on DSM IV. In the IDAF-S module, the
index distinguishes specifically between dental fear and phobia. fear-inducing potency of various stimuli associated to dental

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 GENERAL DENTISTRY

Table 2 Total number studies that used the evaluated questionnaires and screening tools in decreasing order (PubMed, Web of Science,
Embase, and MedPilot: “Questionnaire completely spelled” out OR as an “abbreviation” AND “dental anxiety” AND/OR “dental phobia”);
Enumeration of studies included in the present review with the number of participants

Questionnaire/ Total number

Study and number of participants included in the present review
screening tool of uses
DAS 1,712 Jaakkola et al4 (26), Kruger et al8 (649), Eitner et al9 (347), Nermo et al14 (986), Sartory et al26 (1,139), Corah37 (1,232),
Naumova et al45 (40), Talo Yildirim et al46 (231), Locker and Liddell48 (2,272), Moore et al49 (155), Johansson and
Berggren50 (41), Tönnies et al51 (137), Humphris et al52 (1,392), Moore et al53 (155), De Jongh et al54 (180), Sartory et al55
(48), Neverlien56 (1,351), Luyk et al57 (45), Schuurs et al58 (620), Facco et al80 (1,114)
DFS 1,680 Jaakkola et al4 (26), Berggren and Meynert16 (160), Talo Yildirim et al46 (231), Johansson and Berggren50 (44), Tönnies et
al51 (137), Moore et al53 (80), Berggren et al68 (100)
DAI 1,155 Stouthard et al71 (1,575), Stouthard et al72 (664)
MDAS 289 White et al6 (308), Appukuttan et al41 (200), Höglund et al43 (1,128), Wannemüller et al44 (823), Humphris et al52 (1,392),
Humphris et al59 (800), Humphris and Hull60 (583), Pekkan et al61 (250), Viinikangas et al62 (823), Milgrom et al63 (480),
Kanegane et al64 (73), Armfield et al65 (104)
VAS 223 Hofer et al5 (46), Appukuttan et al41 (200), Höglund et al43 (1,128), Barthelmes77 (1,820), Facco et al80 (1,114), Luyk et al57
(45), Kanegane et al64 (73)
IDAF-4C+ 143 Wang et al20 (119), Armfield78 (1,511), Tönnies et al79 (287)
DCQ 133 De Jongh et al54 (189), Sartory et al55 (48)
DBS 94 Moore et al49 (80), Moore et al53 (80), Berggren et al68 (100), Milgrom et al63 (480), Abrahamsson et al69 (117), Abrahams-
son et al70 (278)
STAI/STADI 31 Hofer et al5 (46), Wang et al20 (119), Naumova et al45 (40), Talo Yildirim et al46 (231), Moore et al49 (155), Moore et al53
(155), De Jongh et al54 (180), Sartory et al55 (48), Luyk et al57 (45), Humphris and Hull60 (583)
HAQ 24 Enkling et al2 (300), Hofer et al5 (46), Lenk et al25 (212), Sartory et al26 (120), Wannemueller et al36 (126), Wannemueller
et al44 (43), Sartory et al55 (48), Jöhren74 (199), Jöhren et al75 (160), Barthelmes77 (1,820), Facco et al80 (210)
S-DAI 14 Aartman73 (321)
DAQ 10 Neverlien56 (1,351)
SDFQ 10 Jaakkola et al4 (26)

interventions were evaluated.79 This index is suited for: i) the Short Dental Fear Question (SDFQ)
assessment of DA and dental fear at a population or individual
level, ii) making a provisional diagnosis of dental phobia, and The Short Dental Fear Question (SDFQ)4 is a short clinical instru-
iii) determining important fear relevant stimuli for fearful (or ment containing one basic question supplied with four
nonfearful) individuals. IDAF-4C always showed good to excel- response options. The options are based on gradation and rep-
lent evaluation values: internal consistency (Cronbach alpha) resent a four-point Likert scale indicating that the more fear the
0.94, test-retest reliability r = 0.82, and correlation to DAS higher the numerical value. The last option (4) includes three
r = 0.84 and DFS r = 0.89.10,78 items describing situations associated with difficulties during
dental treatment situations give an assumption of whether
treatment may be possible or will definitively fail from the clin-
Single-item Dental Anxiety Question (DAQ)
ically point of view. In options 3, 2, and 1, the degree of diffi-
In the Single-item Dental Anxiety Question (DAQ),56 the ques- culty decreases gradually until it is finally nonexistent.4 Treat-
tion “Are you afraid to go to the dentist?” reduces the number ment is manageable in patients who are moderately or slightly
of questions in the questionnaires to a minimum and pro- frightened or even relaxed.4
vides helpful information about the presence of an anxiety
disorder. The patient assesses the anxiety by self-explaining
Visual Analog Scale (VAS)
and based on predefined answers (no; a little; yes, quite; yes,
very) representing a Likert scale. The correlation to DAS is f assessment using VAS,41 the VAS consists of a scale with
For self-
r = 0.71.56 two defined endpoints (0 to 100 mm). The patient is assessed

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 Bürklein et al

before treatment by marking his/her fear on this scale with a be easily implemented in dental practice. Their validities and
line. The value 0 corresponds to complete freedom from fear and reliabilities have been well investigated and in the end they are
the value 100 to the maximum fear imaginable. A vertical stroke all suitable for recording DA and do not influence or intensify
on the line represents the anxiety level. The VAS offers a cut-off patients anxiety.60,65,88-90 However, most of them do not differen-
value of ≥ 4.8 to discriminate between patients who were and tiate between DA and DAD/phobia. This is of clinical relevance
were not anxious, and a cut-off value of ≥ 7 to identify patients as every second patient with a DAD (dental phobia) has at least
with dental phobia.41 There is a recommendation to use a one additional anxiety disorder. The majority (75%) of the
detailed questionnaire as a supplement starting from a value of patients exhibiting at least two disorders have never been
> 0.5.77,84 The reliability of the VAS is very high and it is character- under psychotherapeutic care.24,25 It has been shown that DA
ized by a good correlation to significantly more extensive ques- and dental fear were related to psychologic status and different
tionnaires in identifying dental anxiety (eg, DAS, MDAS).41,57,77,80,84 anxiety levels, symptoms, and triggers, and reflect the broad
spectrum of fear of dental situations.46,47 It is therefore up to the
dental practitioner, when a phobia is suspected, to provide
Other (objective) methods
psychotherapeutic treatment for these patients.
Further methods such as blood pressure and pulse rate meas- Single item tools or questionnaires, which are compact and
urements as well as pulse oximetry and the recording of finger easy to answer and interpret, and thus convenient for use in a
temperature and galvanic skin response (GSR) were described, busy routine clinical setting by dental practitioners, represent
but only the measurement of GSR has been validated as a the fastest and easiest way to find out whether a dental anxi-
method for recording and diagnosing DA so far.85 GSR measures ety/phobia is present. The single‐item VAS has been suggested
the electrical changes (sweat on the skin reduces the resistance), as suitable for application in the dental clinic.41 The VAS is
which are caused by the slightest secretion from epidermal widely used in psychology and medicine to assess subjective
sweat glands, and allows a conclusion on the perceived fear.86 phenomena, such as pain and quality of life.91 Several studies
The saliva concentration of the stress hormone cortisol was also evaluated the ability of the VAS to rate DA and found it reliable
investigated in several studies.45,64 This procedure seems to be and easy to use.41,84 Like the VAS, the DAQ and SDFQ are suit-
suitable for clinical diagnostics but offers insufficient sensitivity.45 able single-item tools for screening anxious patients. The SDFQ
Only the saliva secretion rate is claimed to be a marker for DA.45 indicates the patient’s potential avoiding behavior, whereas the
VAS may differentiate between fear and phobia. However, it is
questionable if the single-item screening tools are comparable
Discussion
or superior to multi-item tools capturing multidimensional ele-
The null hypothesis has to be partially rejected. On the one ments of dental anxiety.58
hand, the screening tools and questionnaires are suitable for The more comprehensive questionnaires are obviously
recognizing DA and offer good to excellent reliabilities, but on more time consuming and use multiple questions with Likert-
the other hand only a few were able to differentiate between scale scoring, but they offer more detailed information con-
phobia and subclinical anxiety (Table 1). cerning the fear and other aspects like anxiety-triggering stim-
Only a small percentage of dental professionals use any ulating factors. The questionnaires give a general overview of a
form of assessment technique to rate DA.87 If no assessment patient’s dental fear, eg more questions and/or alternative
tool is used, dental professionals may rely on their experience answers. Some represent specific dental fear inventories and
and intuition, usually called the “clinical eye,” to rate a patient’s psychometric instruments concerning several components of
level of DA. Nevertheless, clinicians do not successfully identify DA, such as cognitive, physiologic, behavioral, and emotional
anxious patients without the concurrent use of patient self- f as- aspects. Nevertheless, administration of multi-item question-
sessment tools or any other screening instruments like ques- naires is accompanied by some disadvantages. Time con-
tionnaires.43 Numerous screening tools and questionnaires are straints in clinical practices; self-
f assessment depending on indi-
currently available. They are more or less comprehensive (1 to vidual interpretation, perception, and actual mood; confusion
40 items/questions) and time consuming. Ultimately, objec- due to too few or too many responses; limitation in predefined
tives and information content are decisive for choosing the categorical terms of complex subjective behaviors and infor-
right questionnaire. In general, anxiety questionnaires provide mation on scale; and finally the summation to a general value
additional and more precise information regarding DA and can may lead to incorrect conclusions.92-94

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 GENERAL DENTISTRY

Table 3 Web-based access to the recommended questionnaires according to the German guideline “Dental anxiety in adults”

Questionnaire/
screening tool Available at:
DAS https://www.researchgate.net/figure/Questionnaire-based-on-Corahs-Dental-Anxiety-Scale-DAS-Points-were-assigned-for-the_
fig1_7826989
MDAS https://www.researchgate.net/figure/Modified-dental-anxiety-scale_fig1_325971424
HAQ https://www.researchgate.net/figure/Hierarchical-Anxiety-Questionnaire-HAQ-according-to-Joehren-15_fig3_5654841/amp
DFS https://www.researchgate.net/figure/Dental-fear-survey-questions_fig2_325971424
IDAF-4C https://www.researchgate.net/figure/Dental-fear-survey-questions_fig2_325971424

Irrespective of these limitations, some authors demand to A questionnaire can be validated, but a comparison with
consult a more detailed questionnaire if the VAS value is greater other questionnaires is difficult. If all questionnaires delivered
than 50 on the scale and even advocate the use of more than one identical results, then they would be redundant and superflu-
questionnaire to verify the suspected diagnosis of a DAD.77,84,95 ous. The distribution and popularity of the questionnaires vary
From the clinical point of view, it is important for the practi- greatly (Table 2) due to the availability in the respective lan-
tioner to know whether a dental treatment is possible under guages and due to the different publication dates. Most of the
more or less regular conditions in the dental office or if the common questionnaires (ie, those recommended in the Ger-
patient needs external help from specialists (psychologist or man guideline) are web-based and are made available by the
psychiatrist) to make the situation manageable. Ignoring the authors via ResearchGate (Table 3). Each questionnaire also
latter may be dangerous for both the patient and operator. Only depends on the honesty of the patients, and questionnaires
very few questionnaires differentiate between DA and a phobia. performed in a semi-structured interview represent a tool that
The only tools suitable for a suspected diagnosis (the final diag- depends on several factors (questioner, environment, personal
nosis is reserved for the psychologist) of a DAD or phobia are attitude/mood). There is a lack of evidence regarding which
the DFS, DCQ, HAQ, IDAF-4C, and with constraint the VAS. Aoid- tool is superior, but there is a consensus that it is better to use
ance, claimed to be characteristic for a DAD,68,96 is one of the a screening tool or questionnaire than not to use one at all.60,65,87
central aspects when addressing phobia using the DFS and HAQ However, a questionnaire is never an isolated and sole instru-
whereas the IDAF-4C solely includes a specific phobia module. ment of investigation; it must be carefully analyzed and inter-
The DAS (≥ 15) and VAS (> 0.7) may indicate phobia by exceed- preted in conjunction with a thorough behavioral observation
ing special cut-off values.41,81 of the patient to obtain further information concerning DA.97
Finally, the screening tool or questionnaire to record and Other methods (blood pressure, pulse rate measurements,
evaluate DA should fit to the orientation and focus of the prac- pulse oximetry, GSR, or saliva concentration of the stress hor-
tice and be oriented accordingly. Each questionnaire is suited to mone cortisol) may be suitable to assess objective values of
fulfil this aspect and works even better than dental practitioners’ anxiety levels in clinical diagnostics and may allow a classifica-
experience and intuition in rating a patient’s level of DA. The use tion of these individuals in mildly, moderately, or highly anx-
of questionnaires and screening tools is strongly recommended, ious, or even phobic patients.45,57,63,86 However, most of these
and the dissemination of these useful and valuable tools should techniques offer limited practicability in daily dental practice
be encouraged and supported. Nevertheless, the tools men- due to additional laboratory equipment, costs, and the corre-
tioned have different objectives (eg, cognition, beliefs, control) sponding experience to use the devices and interpret the data
and offer some strengths and weaknesses in screening differ- obtained. Nevertheless, these methods may provide add-on
ences in cognitions and physiologic symptoms of anxious pa- information and allow a kind of monitoring of the patients en-
tients with avoidance compared with nonanxious patients with abling visualization of the heart rate or even neurologic phe-
regard to dental treatment. The experts, nominated for the de- nomena like prepulse inhibition (PPI), in which the startle re-
velopment of the German guideline “Dental anxiety in adults” sponse (SR) is reduced by a weaker prestimulus that minimizes
by the participating scientific societies, agreed that the “diag- the reaction of the organism to a stimulus.98,99 Wannemüller et
nostic tools” were not suitable for evidence-based analysis. al99 also showed that the intramodal affective modulation inter-

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 Bürklein et al

feres with the SR and may even cause its potentiation.44 Hence, of the total length of the VAS, an additional anxiety ques-
the influence of various (lead) stimuli on affective SR-modula- tionnaire should be answered that also addresses different
tion (complexity and duration) is still controversially discussed. treatment situations and stimuli. Well-suited questionnaires
It remains unclear whether a generally higher fearfulness of for this purpose are the DAS, HAQ, MDAS, DFS, and IDAF-4C+.
anxious patients or their specific dental phobia is responsible When high levels of DA are associated with a long avoidance
for their increased SR.99 (> 2 years), the suspected diagnosis of a DAD (phobia) is
When monitoring a patient, dental practitioners may also present, and an expert in the field of psychology (psycholo-
determine the extent of blood injury fear in their patients and thus gist or psychiatrist) should be consulted. This is particularly
estimate the probability of the occurrence of vasovagal or fainting important because every second patient with a DAD has at
symptoms. Syncope in BII may be avoided by applying tension least one other psychologic disorder (comorbidity).24,25
and relaxation to the muscles to raise the blood pressure.100 Hence, ■ Careful observation of the patient in an open interview pro-
these technical devices could provide valuable information. vides additional hints of physical signs of anxiety (vegetative
and general symptoms) as well as typical signs of anxiety be-
havior (eg, avoiding eye contact, hesitant answers, fright re-
Recommendations for dental practitioners
actions). Thus, the dental practitioner – being the first con-
The recommendations according to the German dental anxiety tact in numerous cases – plays a major role in screening,
disorder guideline (Association of the Scientific Medical Societ- observing, and referring patients with anxiety and/or psy-
ies in Germany [AWMF], 083-020)39 are as follows: chologic disorders to psychologic specialists.
■ The first medical history should include a dichotomous ■ The final diagnosis of whether a patient is phobic or not lies
question (“yes” or “no”) about the presence of DA. If the beyond the scope of dentistry, and hence interdisciplinary
patient answers “yes”, the patient’s self-f assessment of anxi- management with a psychiatrist or psychologist is crucial in
ety with a VAS is desirable. If the anxiety is greater than 50% such situations.

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Sebastian Bürklein Christoph Brodowski Private Practice, Dental Clinic Bochum/

Dental Phobia Therapy Centre, Bochum, Germany
Eva Fliegel Private Practice, Dental Clinic Bochum/Dental Pho-
bia Therapy Centre, Bochum, Germany
Hans Peter Jöhren* Center for Dental, Oral and Maxillofacial
Surgery University Witten-Herdecke, Germany; and Private Prac-
tice, Dental Clinic Bochum/Dental Phobia Therapy Centre, Bochum,
Germany
Norbert Enkling* Department of Reconstructive Dentistry and
Gerodontology, University of Bern, Switzerland; and Department
of Prosthodontics, Preclinical Education and Dental Materials Sci-
ence, University of Bonn, Germany
Sebastian Bürklein Central Interdisciplinary Ambulance in the
School of Dentistry, University of Münster, Münster, Germany *Equal contribution

Correspondence: Prof Dr med dent Sebastian Bürklein, Central Interdisciplinary Ambulance in the School of Dentistry, University of
Münster, Albert-Schweitzer-Campus 1, Building W 30, 48149, Münster, Germany. Email: [email protected]

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