Lin et al.

BMC Oral Health (2021) 21:647

https://doi.org/10.1186/s12903-021-02017-w

RESEARCH Open Access

Translation and validation of modified dental

anxiety scale based on adult Taiwan population
Chia‑Shu Lin1,2,3*, Chen‑Yi Lee4,5, Shih‑Yun Wu1,6, Li‑Ling Chen1, Kun‑Tsung Lee4,7, Min‑Ching Wang1,8,9 and
Tze‑Fang Wang10

Abstract
Background: Dental anxiety is associated with negative experiences of dental treatment and dental-visiting behav‑
ior. The Modified Dental Anxiety Scale (MDAS) is widely used for assessing dental anxiety. The study aims to establish
the psychometric properties of a Chinese version of the MDAS based on the Taiwan sample (i.e., T-MDAS).
Methods: The T-MDAS and dental-visiting behavior and experience were assessed for 402 adult subjects recruited
from community and clinical sites. The following psychometric properties were assessed: (a) internal consistency,
(b) temporal stability, (c) criterion-related validity (i.e., the association with the score of Index of Dental Anxiety and
Fear, IDAF-4C), (d) discrimination validity (i.e., the difference in scores between the subjects with and without a habit
of a regular dental visit, and (e) the construct validity from a confirmatory factor analysis (CFA). Results. The T-MDAS
showed good internal consistency (Cronbach’s α = 0.88) and temporal stability (ρ = 0.69, p < 0.001). The score was
significantly correlated with the score of the IDAF-4C (ρ = 0.76, p < 0.001) and differed between subjects who regularly
visited a dentist or not, supporting good criterion-related validity and discrimination validity. Results from CFA sup‑
ports good construct validity. Furthermore, higher dental anxiety was related to the lack of a regular dental visit, feel‑
ing pain during treatment, and feeling insufficient skills and empathy of dentists. A higher proportion of high-dental
anxiety subjects in female subjects (8.5%), compared to male subjects (5.0%), was noted.
Conclusions: The T-MDAS is a valid tool for assessing adult dental anxiety. The score is highly associated with dental-
visiting behavior and experience of dental patients.
Keywords: Dental anxiety, Fear, Pain, Avoidance

Introduction dental anxiety is strongly associated with avoidance or

Dental anxiety is broadly defined as the anxiety related delay of dental treatment [3–5], which in turn exacer-
to dental care, which includes both emotional and cogni- bates patients’ oral disease and leads to a ‘vicious cycle’
tive responses to dental treatment [1]. High dental anxi- of oral health [3]. Moreover, there is a statistically signifi-
ety is markedly associated with the negative experience cant association between individuals with higher dental
of dental treatment and behavior of visiting dentists. For anxiety and the risk of dental phobia, a disorder of spe-
example, a meta-analysis of clinical studies revealed that cific phobia [6]. The prevalence of high dental anxiety is
higher dental anxiety is associated with higher state anxi- remarkably high in adults, ranging from 6 to 12%, accord-
ety and pain across different dental procedures [2]. High ing to previous surveys [7–9]. Therefore, high dental anx-
iety in the adult population has been widely considered
a major challenge in dental treatment and oral public
*Correspondence: [email protected]
1
Department of Dentistry, College of Dentistry, National Yang Ming Chiao
health.
Tung University, No. 155, Sec. 2, Linong Street, Taipei 11221, Taiwan, ROC While different approaches have been proposed for
Full list of author information is available at the end of the article managing patients with high dental anxiety [10, 11],

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Lin et al. BMC Oral Health (2021) 21:647 Page 2 of 11

the fundamental issue of managing dental anxiety is to Materials and methods

assess individual dental anxiety with a valid and reli- Study design
able tool. Assessment of dental anxiety has been rec- The study is a cross-sectional and observational
ommended for all dental patients to screen for patients research focusing on the psychometric properties of
with high dental anxiety, so that their experience of the T-MDAS and dental-visiting behavior and experi-
treatment, can be improved [12]. A variety of tools ence of the adult Taiwan population. The subjects were
for assessing dental anxiety, dated back to the four- recruited from community and clinical sites. The fol-
item Dental Anxiety Scale (DAS) [13]. Extending the lowing psychometric properties of the T-MDAS were
original DAS, Humphris et al. developed the Modified assessed: (a) internal consistency, (b) temporal stability,
Dental Anxiety Scale (MDAS), which consists of five (c) criterion-related validity (i.e., the association with
questions of two domains of dental treatment [14]. The the score of Index of Dental Anxiety and Fear, IDAF-
two domains include the Anticipatory Dental Anxiety, 4C) [25],
which relates to the feeling when individuals are about
to receive dental treatment, and the Treatment Dental Participants
Anxiety, which relates to the feeling when individuals The psychometric properties of the T-MDAS were eval-
are receiving a specific dental procedure (e.g., scal- uated based on the samples from both a community
ing or an injection of local anesthetics) [8]. With good and a clinical site. For the community sample (n = 201),
validity, reliability, and simplicity (i.e., only five ques- subjects were recruited via advertisements posted in
tions), the MDAS has been translated into multiple the local community and the university campus of
languages and widely used for the clinical assessment National Yang-Ming University. For the clinical sample,
of dental anxiety in the world [15–20]. subjects were recruited in the outpatient department of
Dental anxiety is associated with several factors the Department of Stomatology, Taipei Veterans Gen-
intrinsic to dental treatment. For example, a worse eral Hospital (n = 201). We recruited the subjects with
experience of dental treatment (including pain) and the following inclusion criteria: (a) aged between 20
a poor patient-dentist relationship may contribute to and 90 years and (b) being able to communicate with
dental anxiety and fear [21, 22]. However, the associa- the experimenters verbally, and the following exclusion
tion between dental anxiety and the ‘extrinsic factors’ criteria: (a) having a history of major physical or psy-
of dental treatment, including the approachability of chiatric disorders and (b) feeling stressed when com-
dental service and the financial burden of treatment, pleting the questionnaires related to fear and anxiety of
has remained unclear. In Taiwan, most procedures of dental treatment. The same study sample also partici-
preventing and treating oral diseases, including caries pated in another study regarding negative experience
restoration, ultrasound scaling, extraction, and root of dental treatment, which results are published in a
canal treatment, are covered by the system of National previous study [26]. All the questionnaires were col-
Health Insurance (NHI) [23]. In the meantime, there lected by the same researcher (L–L Chen). The study
is an abundant supply of dental manpower [24], espe- was approved by the institutional review board (IRB)
cially for local dental clinics in urban areas. All the of National Yang-Ming University (YM106095E) and
factors reduce the barrier to a regular dental visit. the IRB of Taipei Veterans General Hospital (2018–12-
Therefore, investigating the association between den- 003AC). All the subjects completed a written informed
tal anxiety and dental-visiting behavior and experience consent before the study started. The study is con-
in Taiwan may provide new insights into the extrinsic ducted in accordance with the Declaration of Helsinki.
factors of dental anxiety.
The current study has three major research aims.
Estimation of sample size
First, we reported the psychometric properties (i.e.,
The sample size of the study is estimated using G*Power
criterion-related validity, discrimination validity, con-
ver. 3.1.2 [27] with the following conditions. (a) We
struct validity, internal consistency, and temporal
hypothesized that the T-MDAS score would discrimi-
stability) of a Chinese version of the MDAS based on
nate between the subjects with and without a habit of
the Taiwan sample (i.e., T-MDAS). Second, we investi-
a regular dental visit, as evidence of the validity of the
gated the association between dental anxiety and den-
T-MDAS. Therefore, the Mann–Whitney U test was
tal-visiting behavior and experience. Additionally, we
adopted for hypothesis testing. (b) An analysis of sta-
estimated the proportion of high-dental anxiety indi-
tistical power was performed by controlling α = 0.05
viduals, based on the results of the T-MDAS.
and power = 0.85 (i.e., β = 0.15), with a moderate effect
size (d = 0.45). Based on the calculation, we estimated
Lin et al. BMC Oral Health (2021) 21:647 Page 3 of 11

the minimal sample size as 188 for each site of the sam- non-parametric tests were used for the statistical analy-
ple (community or clinics) and 376 for both sites of the sis. All the statistical analysis was performed using IBM
sample. SPSS Statistics (ver. 24.0) (IBM, Armonk, NY, USA),
except for the confirmatory factor analysis (CFA), which
Assessment tools was performed using LISREL (ver. 10.20) (Scientific Soft-
Preparation of the Taiwan MDAS (T‑MDAS) ware International, Inc., Lincolnwood, IL, USA).
The original English version of the MDAS developed by
Humphris et al. [14] was translated by a dentist (K-T Lee) Analysis of Reliability of the T‑MDAS
to Traditional Chinese. The Chinese version was back- For the five questions of the T-MDAS, internal consist-
translated into English and validated independently by ency was assessed using Cronbach’s alpha. For assessing
another dentist (C-S Lin). The quality of the translation temporal stability, 30 subjects were asked to perform
was then independently assessed by a pedodontist (M-C the same questionnaires again after the first assessment,
Wang) for expert opinions, respectively for each of the with a delay of five to six weeks (mean = 5.7 weeks).
five questions. The assessment showed a good quality of The strength of association between the test and re-test
translation (mean point = 4.6) based on a 1–5 five-point scores was assessed using Spearman’s rho coefficient
numerical scale (1 = Very poor quality and 5 = Very good and the difference between the two tests was assessed
quality). using the Wilcoxon Signed-rank test. Additionally, the
intraclass correlation coefficient (ICC) was calculated to
The index of dental anxiety and fear (IDAF‑4C) assess the agreement and consistency between the test
The IDAF-4C consists of eight questions that assess and re-test scores.
the emotional, cognitive, behavioral, and physiological
aspects related to dental anxiety and fear [25]. A Chinese Analysis of Validity of the T‑MDAS
version has been previously translated from the original We first investigated the criterion-related validity
English version and demonstrates a good clinical validity, by assessing the strength of association between the
based on Taiwanese subjects who received extraction of T-MDAS score and the IDAF-4C score (as the criterion),
wisdom teeth [28]. In the current study, we adopted the using Spearman’s rho coefficient. Second, we performed
score from the IDAF-4C as the criterion for evaluating an analysis on the discrimination validity of the T-MDAS.
the criterion-related validity of the T-MDAS. The scores Because dental anxiety is highly associated with patient
from the two scales have revealed a high correlation in behavior of dental visiting [3, 4], we hypothesized that
previous research [29]. the T-MDAS score would discriminate between the sub-
jects with and without a habit of a regular dental visit.
Dental‑visiting behavior and experience The difference was assessed using the Mann–Whitney
The behavior and experience related to dental visiting U test. In addition, we performed a CFA to assess the
were assessed using customized questions. Five vari- construct validity of the T-MDAS [30]. We tested the
ables were collected via the following questions: (a)’How two-factor model that differentiates anticipatory dental
do you think about your oral function?’ (Perceived Oral anxiety and treatment dental anxiety [8] and assessed the
Function), (b) ‘When you feel something uncomfort- overall model fit. The following indices were evaluated:
able about your mouth, teeth, or gum, what would you the comparative fit index (CFI), the goodness of fit index
do first? (Choices of Oral Care), (c) ‘When was the last (GFI), the normed fit index (NFI), and the root mean
time when you visit a dentist? (Latest Visit), (d) ‘Have square error of approximation (RMSEA).
you had any unpleasant experience about visiting a den-
tist? (Negative Experience with Dentists), and (e) ‘Do Association between dental anxiety and dental‑visiting
you regularly visit a dentist’ (Regular Dental Visits). The behavior and experience
variables ‘Choices of Oral Care’ and ‘Negative Experi- We focused on the following variables of dental-visiting
ence with Dentists’ consist of multiple choices. Subjects behavior and experience, as defined in the previous sec-
were instructed to choose all the items they agreed. See tion: (a) Perceived Oral Function, (b) Choices of Oral
Table 1 for the response items of each question. Care, (c) Latest Visit, and (d) Negative Experience with
Dentists. For the variable Perceived Oral Function, the
Statistical analysis Kruskal Wallis test was performed for assessing the dif-
We first examined the normality of the score distri- ference in the T-MDAS score between subjects who
bution of the T-MDAS score and the IDAF-4C score. reported ‘Very Good’, ‘Good’, ‘Moderate’, ‘Poor’, and
All the scores are non-normally distributed, based on ‘Very Poor’ oral functions. For the variable Latest Visit,
the Shapiro–Wilk test (p < 0.05) (Table 1). Therefore, the Kruskal Wallis test was performed for assessing the
Lin et al. BMC Oral Health (2021) 21:647 Page 4 of 11

Table 1 Results of descriptive analysis

n (%) Mean Median S.D Min Max

Gender
Male 202 (50.2)
Female 200 (49.8)
Age1 47.0 47.0 16.5 20.0 86.0
Site
Community 201 (50.0)
Clinical 201 (50.0)
T-MDAS1 10.6 10.0 4.3 5.0 25.0
IDAF-4C1 1.8 1.4 0.9 1.0 5.0
Regular dental visits
No 167 (41.5)
Yes 235 (58.5)
Perceived oral function
Very good 25 (6.2)
Good 84 (20.9)
Moderate 217 (54.0)
Poor 56 (13.9)
Very poor 20 (5.0)
Choices of oral care2
Visiting a dentist 354 (88.1)
Topical medication 18 (4.5)
Taking analgesics 37 (9.2)
Ignoring it 56 (13.9)
Others 8 (2.0)
Latest visit
Within 6 months 266 (66.2)
6 months–2 years 88 (21.9)
More than 2 years 48 (11.9)
Negative experience with dentists2
Never visiting a dentist 1 (0.2)
No negative experience 258 (64.2)
Pain during treatment 71 (17.7)
Insufficient skills 69 (17.2)
Insufficient empathy 41 (10.2)
Poor communication 33 (8.2)
Others 37 (9.2)
1
The scores are non-normally distributed, based on the Shapiro–Wilk test (p < 0.05)
2
Subjects are allowed to choose more than one item
Max.: maximum, Min.: minimum, IDAF-4C: index of dental anxiety and fear, S.D.: standard deviation, T-MDAS: the Chinese version of the modified dental anxiety scale
based on the Taiwanese sample

difference in the T-MDAS score between subjects who was made between the subjects who took analgesics for
had their last visit ‘Within 6 months’, ‘6 months-2 years’, oral care and those who did not. And in Negative Experi-
and ‘More than 2 years’. For the variables Choices of Oral ence with Dentists, a comparison was made between the
Care and Negative Experience with Dentists, the Mann– subjects who felt insufficient skills of dentists and those
Whitney U test was performed, respectively for compar- who did not.
ing the T-MDAS score between the subjects who chose
and who did not choose each response item of the varia-
bles. For example, in Choices of Oral Care, a comparison
Lin et al. BMC Oral Health (2021) 21:647 Page 5 of 11

The proportion of high‑dental anxiety individuals the IDAF-4C score was performed between subjects of
To estimate the proportion of high-dental anxiety indi- different genders and subjects’ samples from the com-
viduals from our samples, we adopted the cut-off value munity vs. the clinical sites. As shown in Table 2, no sig-
(19 points) for high-dental anxiety, which is established nificant difference is found for subjects’ age, the T-MDAS
by previous studies based on a U.K. sample [6, 7]. We first score, and the IDAF-C score, between the community
calculated the distribution of the T-MDAS score from and the clinical samples. Therefore, data from the two
our sample. And the proportion of high-dental anxiety samples were combined for the subsequent analyses. The
individuals was calculated according to the cumulating female subjects showed a higher T-MDAS score, com-
distribution of the score. Notably, because the T-MDAS pared to the male subjects (two-tailed Mann–Whitney U
score was associated with gender (Table 2), the analysis test, p = 0.002) (Table 2).
was performed separately for female and male subgroups.
Reliability of T‑MDAS
Results The T-MDAS reveals good internal consistency (Cron-
Results of descriptive analysis bach’s α = 0.88). Within the T-MDAS, the scores from
Table 1 shows the results of descriptive analysis, includ- each pair of the five questions were significantly corre-
ing the analysis of age, the T-MDAS score, the IDAF- lated (Table 3). For the 30 subjects who completed a test
4C score, and dental-visiting behavior and experience. and a re-test, their T-MDAS scores between the two tests
The comparison between age, the T-MDAS score, and were significantly correlated (ρ = 0.69, p < 0.001). The test

Table 2 Results of the comparison between genders and sampling sites

Community (n = 201) Female (n = 200)
Age MDAS IDAF-4C Age MDAS IDAF-4C

Mean 45.5 10.5 1.8 47.0 11.3 1.8

Median 46.0 10.0 1.4 47.0 11.0 1.5
S.D 17.1 4.3 0.9 16.4 4.4 0.9
Min 20.0 5.0 1.0 20.0 5.0 1.0
Max 86.0 25.0 5.0 86.0 23.0 4.8
Clinical (n = 201) Male (n = 202)

Mean 48.5 10.8 1.7 47.0 10.0 1.7

Median 48.0 10.0 1.4 47.5 9.0 1.4
S.D 15.8 4.4 0.9 16.6 4.1 0.9
Min 20.0 5.0 1.0 20.0 5.0 1.0
Max 86.0 25.0 5.0 86.0 25.0 5.0
Comparison1 0.072 0.642 0.365 0.976 0.002 0.402
1
The number denotes the p value of Mann–Whitney U test
Max.: maximum, Min.: minimum, IDAF-4C: index of dental anxiety and fear, S.D.: standard deviation, T-MDAS: the Chinese version of the modified dental anxiety scale
based on the Taiwanese sample

Table 3 Correlation between the questions of the T-MDAS and IDAF-4C

Questions of the T-MDAS IDAF-4C
1 2 3 4 5

1 0.76 0.60 0.48 0.45 0.68

2 0.68 0.52 0.50 0.69
3 0.56 0.60 0.65
4 0.52 0.56
5 0.52
All the correlation was assessed using Spearman’s rho coefficient. All the results are statistically significant (p < 0.01)
IDAF-4C: index of dental anxiety and fear, T-MDAS: the Chinese version of the modified dental anxiety scale based on the Taiwanese sample
Lin et al. BMC Oral Health (2021) 21:647 Page 6 of 11

and re-test scores were not significantly different (two- Association between dental anxiety and dental‑visiting
tailed Wilcoxon signed-rank test, p > 0.05). An analysis of behavior
the ICC revealed that, for the two-factor mixed model, For the variable Perceived Oral Function, subjects
the test and re-test scores showed good absolute agree- reporting different perception of their oral function
ment (ICC = 0.89) and consistency (ICC = 0.89). The showed a significant difference in the T-MDAS score
results suggest that the T-MDAS shows good temporal (Kruskal Wallis test, p < 0.001). The subjects reporting
stability within a period of around six weeks. a ‘Very Good’ function showed the lowest T-MDAS
score (median = 7.0), while the subjects reporting
Validity of T‑MDAS a’Poor’ function showed the highest T-MDAS score
The T-MDAS scores were significantly correlated with (median = 11.0). For the variable Latest Visit, subjects
the IDAF-4C scores (ρ = 0.76, p < 0.001) (Fig. 1). Moreo- who delayed a dental visit with different periods did
ver, the score from each of the five questions was signifi- not show a significant difference in the T-MDAS score
cantly correlated with the IDAF-4C score, respectively (Kruskal Wallis test, p = 0.26) (Fig. 3).
(Table 3). The result is similar to that based on a Finnish For the variable Choices of Oral Care, the subjects
sample (ρ = 0.74, [29]), suggesting good criterion-related who visited a dentist showed a lower T-MDAS score,
validity. In addition, the correlation was statistically sig- compared to those who did not (Mann–Whitney U test,
nificant for both female and male subgroups (female: p = 0.001). In contrast, the subjects who used analgesic
ρ = 0.74, p < 0.001; male: ρ = 0.79, p < 0.001) (Fig. 1). For and just ignored it showed a higher T-MDAS score,
discrimination validity, we found that subjects who reg- compared to those who did not (Mann–Whitney U test,
ularly visited a dentist showed a lower T-MDAS score p = 0.038 and < 0.001, respectively). The T-MDAS score
(mean = 10.1), compared to those who did not regularly of the subjects who used topical medication and those
visit a dentist (mean = 11.4) (two-tailed Mann–Whit- who did not was not statistically significant (Mann–
ney U test, p = 0.021). Consistently, the IDAF-4C assess- Whitney U test, p = 0.063). For the variable Negative
ment showed that subjects who regularly visited a dentist Experience with Dentists, the subjects without negative
showed a lower IDAF-4C score (mean = 1.6), compared experience showed a lower T-MDAS score, compared
to those who did not regularly visit a dentist (mean = 2.0) to those who did not (Mann–Whitney U test, p < 0.001).
(two-tailed Mann–Whitney U test, p < 0.001). The In contrast, the subjects with pain during treatment
result supports for good discrimination validity of the showed a higher T-MDAS score, compared to those
T-MDAS. For construct validity, the CFA revealed who did not (Mann–Whitney U test, p < 0.001). The
that the data from the T-MDAS fit well to the two-fac- subjects who felt insufficient skills of dentists showed
tor model (χ2 = 10.5, p = 0.032, with RMSEA = 0.06, a higher T-MDAS score, compared to those who did
CFI = 0.99, GFI = 0.99 NFI = 0.99) (Fig. 2). The finding not (Mann–Whitney U test, p = 0.010). The subjects
supports for good construct validity of the T-MDAS. who felt insufficient empathy of dentists showed a
higher T-MDAS score, compared to those who did not
(Mann–Whitney U test, p = 0.006). Finally, the subjects
who felt poor communication with dentists showed a

Fig. 1 Association between the score of the Taiwan Modified Dental Anxiety Scale (T-MDAS) and the score of the index of dental anxiety and fear
(IDAF-4C). The scores are significantly correlated for all the subjects and for the male and the female subgroup, respectively
Lin et al. BMC Oral Health (2021) 21:647 Page 7 of 11

Fig. 2 The path diagram of the confirmatory factor analysis. The results show that the T-MDAS score fits well to a two-factor model (anticipatory
dental anxiety and treatment dental anxiety)

Fig. 3 Association between the T-MDAS score and dental-visiting behavior and experience. The T-MDAS score significantly differs between different
degrees of Perceived oral function, but not between the duration of Latest visit. The T-MDAS score significantly differs in the choices of oral care
and negative experience with dentists in the subjects. Please note that the category ‘negative experience (NO)’ denotes the results that subjects
responded ‘YES’ in the question ‘No negative experience’ and the category ‘negative experience (YES)’ denotes the results that subjects responded
‘NO’ in the question ‘no negative experience’. The modification is made to unify the direction of comparison across each item
Lin et al. BMC Oral Health (2021) 21:647 Page 8 of 11

Fig. 4 The proportion of high dental anxiety subjects. (A) The statistical distribution of the T-MDAS score for all the subjects and gender subgroups.
All the distributions show a rightward-skewed pattern. (B) The cumulating distribution of the score reveals a higher proportion of high-dental
anxiety subjects in the female subgroup, compared to the male subgroup

higher T-MDAS score, compared to those who did not, proportion also differs between gender subgroups. The
with a trend of statistical significance (Mann–Whitney proportion of subjects with the T-MDAS score ≧ 19 was
U test, p = 0.056) (Fig. 3). 8.5% and 5.0%, respectively for the female and the male
subgroups (Fig. 4B).
The proportion of high‑dental anxiety individuals
Figure 4A shows the distribution of the T-MDAS score Discussion
for all subjects and the female and the male subgroups, Major findings of the study
respectively. The score distribution presents a right- First, our results showed good criterion-related valid-
ward-skewed pattern, with the mode score at 7–8 points ity, discrimination validity, construct validity, internal
(Fig. 4A). The pattern suggests that while most subjects consistency, and temporal stability for the T-MDAS, a
show lower dental anxiety, a few subjects show a great Chinese version of the MDAS based on Taiwan adults.
degree of dental anxiety. Notably, the male subgroup Second, we found that several behavioral factors were
showed more subjects with a lower (i.e., 5–10) T-MDAS related to higher dental anxiety, including the lack of a
score and fewer subjects with a higher (i.e. > 11) T-MDAS regular dental visit, the use of analgesics for oral care,
score, compared to the female subgroup. The pattern of and ignorance of treatment, when subjects felt uncom-
the distribution corresponds to the gender-related differ- fortable with their oral status. A poor perception of oral
ence in the T-MDAS score (Table 2). We estimated the function and worse experience with dentists, including
proportion of high-dental anxiety individuals, accord- feeling pain during treatment, feeling insufficient skills
ing to the cut-off value (19 points) established by previ- and empathy of dentists, and poor patient-dentist com-
ous studies [7, 31]. As shown in Fig. 4B, for all subjects, munication, were associated with higher dental anxiety.
6.7% of them reported the T-MDAS score ≧ 19. The Finally, we found that within our sample, 6.7% of the
Lin et al. BMC Oral Health (2021) 21:647 Page 9 of 11

subjects showed high dental anxiety. The proportion hands [39]), the willingness to report pain may differ due
differed between the female (8.5%) and the male (5.0%) to the gender role (e.g. an expectation to be ‘macho’ for
subgroups. male individuals) [39]. Notably, the IDAF-4C score did
not reveal a significant gender-related difference (two-
Association with dental anxiety and dental‑visiting tailed Mann–Whitney U test, p = 0.40) (Table 2). The
behavior and experience gender-effect, as assessed using the IDAF-4C, is less
By definition, dental anxiety focuses on ‘dental care- clear-cut in the literature. For example, previous stud-
related’ anxiety [32]. Therefore, the factors intrinsic to ies showed a significant gender-related difference in the
dental treatment, such as the patient-dentist relationship summed IDAF-4C score from Australian population
[21], negative experience of treatment [22], and pain [2], (female: 15.20, male: 13.56) [12], but insignificant dif-
have been conceived as the major factors contributing to ference in the mean IDAF-4C score from Finnish popu-
dental anxiety and fear. Our findings revealed an associa- lation (female: 1.49, male: 1.36) [29]. The discrepancy
tion between dental fear and anxiety and these intrinsic between the results from the MDAS and the results from
factors similar to that reported by previous studies. For the IDAF-4C may be accounted for by the questions from
example, we found that subjects with a negative experi- the assessments. In contrast to the T-MDAS that primar-
ence of dental treatment showed a higher T-MDAS score, ily focuses on the emotional aspects of dental anxiety
compared to those who did not. In addition, subjects who (e.g., how anxious one feels), the IDAF-4C, addition-
perceived that dentists lack skills, empathy, and good ally, focuses on the behavioral and cognitive aspects of
communication with patients, showed a higher T-MDAS anxiety (e.g., to delay making appointments or to expect
score, compared to those who did not. A recent study something really bad) [25]. Therefore, the gender-related
revealed that in the primary dental care services of the difference in emotional experience can be less weighted
UK, patients’ anxiety of dental treatment was effectively in the IDAF-4C, compared to that in the T-MDAS.
reduced when dental staff performed anxiety screen-
ing for the patients [33]. Such an active engagement of a Comparison between the current and previous findings
short questionnaire assessment, as part of good commu- Notably, when setting the cut-off point of high-dental
nication between patients and dental staff, may confer a anxiety at 19 points, we found the proportion of high-
beneficial effect for relieving patients’ anxiety [33]. Fur- dental anxiety individuals in our study is lower than that
thermore, results from a cross-sectional survey in the UK reported by previous studies, which adopted the same
revealed that dental anxiety is associated with patients’ cut-off point (e.g., 6.8% for a clinical sample from the
trust in dentists and their feelings of shame about their U.S. [9], 8.7% for a community sample from China [8],
oral condition [34]. Consistently, our findings revealed and 11.6% for a sample from the U.K. [31]). The differ-
that higher dental anxiety was associated with subjects’ ence in the proportion of high-dental anxiety individuals
perception of the lack of skills and empathy of dentists. may be interpreted from several aspects. In addition to
The findings suggest that dental anxiety is highly associ- the ‘intrinsic factors’ that relate to dental treatment per
ated with patients’ experience during treatment, in which se (e.g., pain and poor patient-dentist relationship), there
patient-dentist interaction may play a key role. would be some extrinsic factors contributing to den-
tal fear, such as the approachability of dentists and the
financial burden of receiving dental treatment. In Taiwan,
Gender‑related difference in dental anxiety most items of dental treatment, from preventive proce-
Our result is consistent with the previous findings from dures (e.g., caries restoration and ultrasound scaling) to
different countries, which showed a higher MDAS score relatively invasive procedures (e.g., extraction of wisdom
in female subjects, compared to male subjects (e.g., teeth and root canal treatment) are covered by the system
Turkey [35], China [8], Italy [15]). Consistently, clinical of NHI. Therefore, patients may receive treatment with-
research revealed that female patients may report higher out much financial burden. Meanwhile, there is a high
pre-procedural anxiety before receiving intra‐oral buc- density of private dental clinics in the urban area in Tai-
cal mucosa biopsy [36] and extraction of horizontally wan [40]. Therefore, the great approachability to dentists
impacted wisdom teeth [28], and medical procedures, may contribute to the relatively lower proportion of high-
such as gastroscopy [37]. Because pain of dental treat- dental anxiety individuals in our sample.
ment is markedly associated with anxiety, a potential
interpretation of the gender-related difference in dental Limitations of the current study
anxiety is that female and male subjects differ in pain The findings of our study should be interpreted carefully
perception. Notably, while both genders may have simi- with several limitations. First, we assessed the subjects
lar pain threshold (e.g., heat pain stimuli at lips [38] and both from community and clinical sites. However, both
Lin et al. BMC Oral Health (2021) 21:647 Page 10 of 11

sites are located in the urban area in northern Taiwan. Consent for publication
Not applicable.
Therefore, the results may not fully represent the whole
national population. Second, our results showed a strong Competing interests
association between dental anxiety and dental-visiting All the authors declare no competing of interests.
behavior and experience. However, as a cross-sectional Author details
and observational study, it is difficult to conclude the 1
Department of Dentistry, College of Dentistry, National Yang Ming Chiao
cause-effect relationship between dental anxiety, dental- Tung University, No. 155, Sec. 2, Linong Street, Taipei 11221, Taiwan, ROC.
2
Institute of Brain Science, National Yang Ming Chiao Tung University, Hsinchu,
visiting behavior, and the related experience. Thirdly, Taiwan. 3 Brain Research Center, National Yang Ming Chiao Tung University,
when evaluating the proportion of high-dental anxiety Hsinchu, Taiwan. 4 Department of Oral Hygiene, College of Dental Medicine,
subjects, we followed the cut-off point based on a U.K. Kaohsiung Medical University, Kaohsiung, Taiwan. 5 Department of Medical
Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. 6 Division
sample [6, 7] to compare our results with the previous of Family Dentistry, Department of Stomatology, Taipei Veterans General
findings using the same cut-off point. However, the cut- Hospital, Taipei, Taiwan. 7 Division of Clinical Dentistry, Department of Den‑
off point may not validly discriminate the clinical symp- tistry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. 8 Department
of Dentistry, Taipei Municipal Wanfang Hospital, Taipei, Taiwan. 9 Department
toms of high dental anxiety or dental phobia in Taiwan. of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan. 10 Department
Further research is required to establish a valid cut-off of Nursing, College of Nursing, National Yang Ming Chiao Tung University,
point for clinical usage. Hsinchu, Taiwan.

Received: 8 June 2021 Accepted: 7 December 2021

Conclusion
The T-MDAS is a valid tool for assessing adult dental
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