pISSN 2383-9309❚eISSN 2383-9317

Review Article J Dent Anesth Pain Med 2023;23(4):193-212❚https://doi.org/10.17245/jdapm.2023.23.4.193

What is the gold standard of the dental anxiety scale?

Seong In Chi
Department of Pediatric Dentistry, Sejong Dental Hospital, School of Dentistry, Dankook University, Sejong, Republic of Korea

It is important to understand patients' anxiety and fear about dental treatment. A patient's anxiety can be quantified
through a self-report questionnaire, and many related scales have been developed. In this review, I tried to
find out which scale is most suitable for the patient's dental anxiety and fear evaluation by examining the contents
of previously developed scales and comparing the strengths and weaknesses of each scale.

Keywords: Anxiety Scale; Dental Anxiety; Dental Fear; Self Report; Surveys and Questionnaires

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in
any medium, provided the original work is properly cited.

INTRODUCTION and many dentists in each country are also concerned

about addressing this issue. The degree held by dentists
is referred to as Doctor of Dental Surgery (DDS). As
Dental anxiety and fear (DAF) can significantly lower dental treatments primarily involve surgical interventions,
a patient's quality of life in a number of ways. they can potentially trigger "needle phobia" and "blood
Nevertheless, the influence of this issue is often phobia." In addition, there is a term called "dental phobia"
underestimated. When was DAF first recognized? The that specifically addresses the fear of dentistry. This term
fact that nitrous oxide, known as laughing gas, was first emphasizes that dental anxiety is a distinct issue that
discovered as an anesthetic by the dentist Horace Wells dentists should never overlook or underestimate. Anxiety
suggests that the history of DAF is also longstanding [1]. is a subjective experience that is difficult to quantify.
Dental fear has been ranked fifth among the most However, there are three methods through which anxiety
common fears [2]. can be measured: self-report (e.g., questionnaire),
DAF is a global issue that affects people worldwide. physiological measures (e.g., heart rate, amount of saliva,
While there may be variations in the prevalence of DAF sweat on palms), and overt behavior measures (e.g.,
among different races, countries, and cultures, research avoiding eye contact, fidgeting) [4]. Among these
papers on the same topic have been published worldwide methods, using a questionnaire for self-reporting anxiety
[3]. Moreover, there are over dozens of DAF scales that measurement is strongly associated with assessing
have been developed to date, and they exist in various subjective experiences of anxiety and pain in patients [5].
countries around the world. This signifies that a Anxiety and fear are subjective experiences that vary
significant number of individuals are suffering from DAF, in terms of intensity, severity, and the way they are

Received: June 23, 2023•Revised: July 20, 2023•Accepted: July 25, 2023
Corresponding Author: Seong In Chi, Department of Pediatric Dentistry, Dankook University Sejong Dental Hospital, 3rd-floor Dankook building, 87, Do-um 8-ro,
Sejong, 30107, South Korea
Tel: +82-44-410-5066 Fax: +82-44-410-5000 E-mail: g9inc@naver.com
Copyrightⓒ 2023 Journal of Dental Anesthesia and Pain Medicine

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Seong In Chi

Dental Anxiety Scale

1. If you had to go to the dentist tomorrow, how would you feel about it?
a) I would look forward to it as a reasonably enjoyable experience.
b) I wouldn’t care one way or the other.
c) I would be a little uneasy about it.
d) I would be afraid that it would be unpleasant and painful.
e) I would be very frightened of what the dentist might do.
2. When you are waiting in the dentist’s office for your turn in the chair, how do you feel?
a) Relaxed.
b) A little uneasy.
c) Tense.
d) Anxious.
e) So anxious that I sometimes break out in a sweat or almost feel physically sick.
3. When you are in the dentist’s chair waiting while he gets his drill ready to begin working on your teeth, how do you feel? (Same alternatives
as number 2.)
4. You are in the dentist’s chair to have your teeth cleaned. While you are waiting and the dentist is getting out the instruments which he
will use to scrape your teeth around the gums, how do you feel?[8] (Same alternatives as number 2.)

Points were assigned for the subject’s choices, with one point for an (a) choice to 5 points for an (e) choice.
Fig. 1. Corah Dental Anxiety Scale (DAS) [9]

expressed by individuals. Therefore, objective quantifi- availability of an abstract written in English.

cation of these experiences is not an easy task. - Full text available
Furthermore, anxiety itself has various characteristics, - Scale for adult
making it challenging to fully understand and - Only for dental use
comprehend [6]. As a result, numerous dental anxiety 3. Exclusion Criteria
scales have been developed over time, and the process - Scale for adolescent/children
of developing such scales is still ongoing. As a dentist, - Not written in the English language
understanding dental anxiety scales can be helpful in - Full text is not available
comprehending and managing patient anxiety and fear. - Not for dental use only
Therefore, the goal of this review is to analyze and
contrast the numerous dental anxiety scales that have been If possible, I attempted to find the original papers
produced thus far in order to determine their strengths related to the development of the scales. If that was not
and weaknesses. possible or the original paper did not include the full
contents of the scale, I cited other papers that included
MATERIALS AND METHODS the full details of the scale.

ADULT DENTAL ANXIETY SCALE

1. Terms related to ((evaluation OR development OR
prevalence) of) AND/OR (dental anxiety OR dental
1. Corah Dental Anxiety Scale (DAS) [7]
fear OR dental cognition OR dental phobia)
AND/OR (scale OR survey OR questionnaire) were According to this review, the DAS developed by Corah
searched through Google Scholar. Then, related in 1969 is the first-ever dental anxiety scale. DAS consists
papers cited in each paper were searched of 4 questions, making it easy to use [8]. The DAS is
sequentially. a 5-point scale that allows respondents to answer
2. Inclusion Criteria accordingly (Fig. 1). The first question asks, "How would
- The only requirement for inclusion was the you feel if you had to visit a dentist tomorrow?" The

194 J Dent Anesth Pain Med 2023 August; 23(4): 193-212

 Dental Anxiety Scale

possible answers are: I would look forward to the visit. Modified Dental Anxiety Scale
(1)/I would not care one way or the other. (2)/I would 1. If you went to your dentist for TREATMENT TOMORROW, how
would you feel?
be slightly uncomfortable. (3)/I would be quite Not anxious □=[1]
Slightly anxious □=[2]
uncomfortable and fearful of the pain. (4)/I would be
Fairly anxious □=[3]
extremely fearful of what the dentist might do. (5) The Very anxious □=[4]
Extremely anxious □=[5]
higher the score, the higher the dental anxiety level can
be considered. The second, third, and fourth questions 2. If you were sitting in the WAITING ROOM (waiting for the
treatment), how would you feel?
inquire about the respondents' feelings during different Not anxious □=[1]
situations related to dental visits. These situations include Slightly anxious □=[2]
Fairly anxious □=[3]
waiting in the dental office on the day of the appointment, Very anxious □=[4]
just before the dentist starts using the dental drill, and Extremely anxious □=[5]

when the dentist is preparing to do scaling. The possible 3. If you were about to have your TEETH DRILLED, how would you
feel?
answers to these questions are: “I feel comfortable.” (1),
Not anxious □=[1]
“I feel slightly uncomfortable.” (2), “I feel tense.” (3), Slightly anxious □=[2]
Fairly anxious □=[3]
“I feel anxious.” (4), and “I feel extremely anxious to Very anxious □=[4]
the point of sweating or feeling actual physical Extremely anxious □=[5]
discomfort.“ (5). As with the first question, higher scores 4. If you were about to have your TEETH SCALED AND POLISHED,
indicate higher levels of dental anxiety. The total dental how would you feel?
Not anxious □=[1]
anxiety score is calculated by summing up the scores Slightly anxious □=[2]
from the four questions. The scores range from 4 to 20, Fairly anxious □=[3]
Very anxious □=[4]
and the patient's level of anxiety is quantified as follows: Extremely anxious □=[5]
a total score of 4 indicates "no fear”, a score between
5. If you were about to have a LOCAL ANAESTHETIC INJECTION in
5 and 8 corresponds to "low fear”, a score between 9 your gum, above an upper back tooth, how would you feel?
Not anxious □=[1]
and 14 indicates "moderate fear”, and a score between
Slightly anxious □=[2]
15 and 20 corresponds to "high fear" [9]. These scores Fairly anxious □=[3]
Very anxious □=[4]
help evaluate the level of dental anxiety experienced by Extremely anxious □=[5]
the patient. As a father of dental anxiety scale, DAS is Fig. 2. Modified Dental Anxiety Scale (MDAS) [8]
considered the benchmark for dental anxiety scales and
serves as the most appropriate reference for newly or feel physically sick"). As a result, the scale's content
developed scales. While it has faced criticism in some is not monodimensional, meaning it doesn't measure
studies, it continues to be widely cited as the standard dental anxiety along a single consistent dimension [6].
for dental anxiety assessment [10]. In fact, numerous Third, DAS was not able to detect the effect of the
research papers compare correlation coefficients with this dentist-patient relations on dental anxiety [11].
scale when introducing newly created scales. There are
2. Modified Dental Anxiety Scale (MDAS) [12]
indeed several criticisms regarding the disadvantages of
the DAS. First, it lacks content related to an important In 1995, 26 years after the development of DAS, the
aspect of dental treatment, which is local anesthesia MDAS was created by Humphris et al. from the United
injection. Secondly, the content used in questions 2, 3, Kingdom (Fig. 2). MDAS differs from DAS in two main
and 4 includes some items that pertain to emotional states aspects [8]. Firstly, it includes an additional question that
(such as "relaxed" or "anxious") and others related to asks about the patient's feelings just before receiving a
physical reactions (such as "tight," "break out in a sweat "local anesthetic injection," making five questions.

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Seong In Chi

Gale’s Ranking Questionnaire (RQ) Avoidance of dentistry

(1. Never . . . 5. Often)
Situation
1. Have avoided calling for appointment
Dentist is pulling your tooth 2. Have canceled or not appeared
Dentist is drilling your tooth Felt physiological responses
Dentist tells you that you have bad teeth (1. None . . . 5. Great)
Dentist holds the syringe and needle in front of you 3. Muscles become tense
Dentist is giving you a shot 4. Breathing increases
Have a probe placed in a cavity 5. Perspiration increases
Dentist laughs as he looks in your mouth 6. Nausea
Dentist squirts air into a cavity 7. Heart rate increases
Sitting in the dentist's waiting room 8. Mouth salivates
Dentist is laying out his instruments Fearfulness of stimuli
Nurse tells you it is your turn (1. None . . . 5. Great)
Getting in the dentist's chair 9. Making an appointment
Dentist is putting in the filling 10. Approaching office
Thinking about going to the dentist 11. Waiting room
Dentist cleans your teeth with steel probe 12. Dental chair
Getting in your car to go to the dentist 13. Smell of office
Dentist looks at your chart 14. Seeing dentist
Dentist places cotton in your mouth 15. Seeing needle
Calling a dentist to make an appointment 16. Feeling needle
Dental assistant places a bib on you 17. Seeing drill
Dentist squirts water in your mouth 18. Hearing drill
Making another appointment with the nurse 19. Feeling drill
Dentist is cleaning your teeth 20. Feeling as if you will gag
Dentist asks you to rinse your mouth 21. Having teeth cleaned
Dentist tells you he is through 22. Feeling pain even after anesthetic injection
23. Generally how fearful are you of dentistry
Fig. 3. Gale’s Ranking Questionnaire (RQ) [13] How fearful were your:
24. Mother
25. Father
Secondly, the content of the response options was 26. Brothers and sisters
27. Childhood friends
changed to assess the degree of anxiety (not anxious(1),
Fig. 4. Dental Fear Survey (DFS) [14]
slightly anxious(2), fairly anxious(3), very anxious(4),
extremely anxious(5)), applying the same response
options for all questions, which is often seen as an The last part instructs the patient to rank 25 dental
improvement over the DAS, where different types of situations in order of their perceived fearfulness. Through
responses were used for each question, which is this study, Gale divided the patients into a low-fear group
considered a weakness of DAS. The scores are calculated and a high-fear group based on the responses in the
in the same manner as DAS, by summing up the second part. In the third part, the study aimed to compare
responses, resulting in a distribution of 5 to 25 points. the priorities of anxiety-inducing situations between the
Higher scores indicate higher levels of anxiety. two groups. However, the results indicated that regardless
of the patient's baseline anxiety levels, the prioritization
3. Gale’s Ranking Questionnaire (RQ) [13]
of anxiety-inducing dental situations was similar for both
The RQ, developed by Gale in the United States in groups.
1972, consists of 29 items divided into three parts (Fig.
4. Dental Fear Survey (DFS) [14]
3). The first part includes three questions related to
demographic variables (sex, age, and number of dental The DFS, developed in 1973, comprises 27 items (Fig.
visits). The second part involves a single question where 4). The DFS, which consists of a total of 4 parts, is
the patient rates the level of fear experienced when designed to assess dental phobia and related behaviors
visiting the dentist, ranging from 1 (no fear) to 7 (terror). in patients. The first part includes two questions that focus

196 J Dent Anesth Pain Med 2023 August; 23(4): 193-212

 Dental Anxiety Scale

1. Has fear of dental work ever caused you to put off making an appointment?
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
2. Has fear of dental work ever caused you to cancel or not appear for an appointment?
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
When having dental work done:
3. My muscles become tense…
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
4. My breathing rate increases…
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
5. I perspire…
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
6. I feel nauseated and sick to my stomach
1 2 3 4 5
Never Once or twice A few times Often Nealy every time
7. My heart beats faster…
1 2 3 4 5
Never Once or twice A few times Often Nealy every time

1 2 3 4 5
None at all A little Some-what Much Very much
8. Making an appointment for dentistry…
9. Approaching the dentist’s office…
10. Sitting in the waiting room…
11. Being seated in the dental chair
12. The smell of the dentist’s office
13. Seeing the dentist walk in…
14. Seeing the anesthetic needle…
15. Feeling the needle injected…
16. Seeing the drill…
17. Hearing the drill…
18. Feeling the vibrations of the drill…
19. Having your theeth cleaned…
20. All things considered, how fearful are you
of having dental work done?
Fig. 5. Modified Dental Fear Survey (MDFS) [38]

on the avoidance behavior of patients with dental phobia. to 5 (great). The third part inquires about the level of
The first question evaluates the extent to which the patient anxiety regarding potential stimuli at the dental clinic and
avoids making appointments for dental treatment or consists of 15 questions. These questions explore anxiety
cancels them, with responses rated from 1 (never) to 5 levels during various dental situations, such as making
(often). The second question assesses whether the patient appointments, waiting in the waiting room, sitting in the
has ever skipped a dental appointment, also rated from dental chair, smelling the dental odor, and hearing the
1 to 5. The second part comprises six questions regarding sound of the dental drill. The response options are similar
somatic reactions to anxiety, evaluating muscle tension, to those in the second part. The last part of the DFS asks
increased respiration, sweating, nausea, increased heart about the anxiety level of the patient's parents, friends,
rate, and increased salivation on a scale from 1 (none) and people around them. The disadvantages of DFS are,

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Seong In Chi

Dental State Anxiety Scale (DSAS)

Below are a number of statements that people have used to describe themselves while they are at the dentist. Read each statement and
then blacken in the appropriate circle on your answer sheet to indicate how you feel at the dentist’s office.
Use this scale: 1 - Not at all
2 - Somewhat
3 - Moderately so
4 - Very much so
1. While at the dentist I feel calm ······························································································································· 1 2 3 4
2. While at the dentist I feel secur ······························································································································ 1 2 3 4
3. While at the dentist I am tense ······························································································································ 1 2 3 4
4. While at the dentist I am regretful ·························································································································· 1 2 3 4
5. While at the dentist I feel at ease ·························································································································· 1 2 3 4
6. While at the dentist I feel upset ····························································································································· 1 2 3 4
7. While at the dentist I worry over possible misfortunes ··························································································· 1 2 3 4
8. While at the dentist I feel rested ···························································································································· 1 2 3 4
9. While at the dentist I feel anxious ··························································································································· 1 2 3 4
10. While at the dentist I feel comfortable ···················································································································· 1 2 3 4
11. While at the dentist I feel self-confident ·················································································································· 1 2 3 4
12. While at the dentist I feel nervous ·························································································································· 1 2 3 4
13. While at the dentist I am jittery ······························································································································ 1 2 3 4
14. While at the dentist I feel “high-strung” ················································································································ 1 2 3 4
15. While at the dentist I am relaxed ···························································································································· 1 2 3 4
16. While at the dentist I feel content ·························································································································· 1 2 3 4
17. While at the dentist I am worried ··························································································································· 1 2 3 4
18. While at the dentist I feel over-excited and “rattled” ···························································································· 1 2 3 4
19. While at the dentist I feel joyful ······························································································································ 1 2 3 4
20. While at the dentist I feel pleasant ························································································································· 1 2 3 4
Fig. 6. Dental State Anxiety Scale (DSAS) [17]

Getz’s Dental Belief Survey (DBS)

Items Main content
1 Dentists don’t like a request Five-point response scale
2 Feel rushed 1 (highly positive beliefs)
3 No clear explanations 2
4 Dentists do not really listen 3
5 Do what he wants to do no matter what I say 4
6 Make me feel guilty 5 (highly negative beliefs)
7 Not sure I can believe what dentist says
8 Say things to try and fool me
9 Do not take my worries seriously
10 Put me down
11 Worry dentists are technically competent
12 If it hurts, don’t think dentist will stop
13 Don’t feel I can stop for rest
14 Don’t feel comfortable asking questions
15 Thought of hearing news keeps me avoiding treatment
Fig. 7. Getz’s Dental Belief Survey (DBS) [20]

firstly, that it has an uneven structure. In the

5. Modified Dental Fear Survey (MDFS) [16]
questionnaire, there are 2 questions on behavioral
response (dental avoidance) and 5 questions on In 1984, the DFS was modified to include 20 items
physiological response, but there are no questions on (Fig. 5). The part that asked about the anxiety level of
cognitive response and emotional response types [15]. the patient's acquaintances was removed. In the second
Secondly, it excludes items related to the dentist's remarks part, one question related to salivation was deleted from
and the interaction between the dentist and patient [6]. the section that inquired about somatic reactions. In the

198 J Dent Anesth Pain Med 2023 August; 23(4): 193-212

 Dental Anxiety Scale

Revised Dental Belief Survey (DBS-R)

Items Main content
1 I am concerned that dentists recommend work that is not really needed Five-point
2 I believe dentists say/do things to withhold information from me response scale
3 I worry if the dentist is technically competent and is doing quality work 1 (highly positive
4 I have had dentists say one thing and do another beliefs)
5 I am concerned that dentists provide all the information I need to make good decisions 2
6 Dentists don’t seem to care that patients sometimes need a rest 3
7 I’ve had dentists seem reluctant to correct work unsatisfactory to me 4
8 When a dentist seems in a hurry I worry that I’m not getting good care 5 (highly negative
9 I am concerned that the dentist is not really looking out for my best interests beliefs)
10 Dentists focus too much on getting the job done and not enough on the patient’s comfort
11 I’m concerned that dentists might not be skilled enough to deal with my fear or dental problems
12 I feel dentists do not provide clear explanations
13 I am concerned that dentists do not like to take the time to really talk to patients
14 I feel uncomfortable asking questions
15 Dental professionals say things to make me feel guilty about the way I care for my teeth
16 I am concerned that dentists will not take my worries (fears) about dentistry seriously
17 I am concerned that dentists will put me down (make light of my fears)
18 I am concerned that dentists do not like it when a patient makes request
19 I am concerned that dental personnel will embarrass me over the condition of my teeth
20 I believe that dentists don’t have enough empathy for what it is really like to be a patient
21 When I am in the chair I don’t feel like I can stop the appointment for a rest if I feel the need
22 Dentists don’t seem to notice that patients sometimes need a rest
23 Once I am in the chair I feel helpless (that things are out of my control)
24 If I were to indicate that it hurts, I think that the dentist would be reluctant to stop and try to correct the problem
25 I have had dentists not believe me when I said I felt pain
26 Dentists often seem in a hurry, so I feel rushed
27 I am concerned that the dentist will do what he wants and not really listen to me while I’m in the chair
28 Being overwhelmed by the amount of work needed (all the bad news) could be enough to keep me from beginning
or completing treatment
Fig. 8. Revised version of Dental Belief Survey (DBS-R) [45]

third part, two questions regarding the feeling of possible consists of 15 questions (Fig. 7). The main focus is to
vomiting and experiencing pain even after anesthesia assess how patients perceive the way dental treatment is
were removed. provided by the dentist [20]. The DBS is divided into
four main parts, each addressing different aspects of the
6. Dental State Anxiety Scale (DSAS) [17]
patient's perceptions [21]. The first part focuses on
Developed in 1982, the DSAS is a modification of the communication-related content (Item nos. 1, 3, 4, 14, and
State-Trait Anxiety Inventory (STAI), a widely used 15), evaluating how patients perceive their
psychological tool to assess general anxiety levels in communication with the dentist. The second part assesses
patients (Fig. 6) [18]. DSAS is tailored to evaluate anxiety the level of trust patients have in their dentist (Item nos.
specifically in dental situations. It comprises a total of 7 and 8). The third part explores the content of
20 questions, and respondents provide answers on a scale belittlement or fear of negative information (Item nos.
of 1 (not at all), 2 (somewhat), 3 (moderately so), or 4 6, 9, and 11). Lastly, the fourth part examines the feeling
(very much so). The questions focus on how the patient of a lack of control (Item nos. 5, 12, and 13) that patients
feels while being at the dental clinic, including emotions may experience. The responses are rated on a scale from
such as feeling calm, secure, tense, regretful, and so on. 1 (indicating highly positive beliefs) to 5 (reflecting
highly negative beliefs).
7. Getz's Dental Belief Survey (DBS) [19]

The original version of the DBS, developed in 1985,

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Seong In Chi

Dental Anxiety Inventory (DAI)

1------------------ ------------------2------------------ ------------------3------------------ ------------------4------------------ -----------------5
Totally untrue Hardly true Partly true Quite true Completely true
1. I become nervous when the dentist invites me to sit down in the chair.
2. I need to go to the toilet more often when I sit in the waiting room thinking that the dentist will say my teeth look bad.
3. When I'm on my way to the dentist and thinking about the anaesthetic, I would rather go back.
4. I sleep badly when I think about having to make an appointment with the dentist.
5. When I lie back in the dentist's chair, I think about never coming back again.
6. When I know the dentist is going to extract a tooth, I am already afraid in the waiting room.
7. When I think of the sound of the drilling machine on my way to the dentist, I would rather go back.
8. I already feel uncomfortable at home when I think that the dentist will make a remark about my teeth.
9. When the dentist is about to give me an anaesthetic, I cling to the arms of the chair.
10. I become afraid in the waiting room when I hear sounds coming from the dentist's surgery.
11. On my way to the dentist, I sweat or freeze at the thought that the dentist will say I brush my teeth badly.
12. When I think of the moment when the dentist blows air into a cavity, I would like to cancel the appointment.
13. When the dentist looks into my mouth, my breathing becomes faster.
14. I want to walk out of the waiting room the moment I think the dentist will not explain what she/he is going to do in my mouth.
15. On my way to the dentist, I feel nervous when I know my teeth will be scaled.
16. I postpone making an appointment with the dentist as long as I can.
17. I feel uncertain when discussing the treatment of my teeth with the dentist.
18. When I am in the waiting room knowing the dentist is going to scale my teeth, I am unable to concentrate on a magazine.
19. When I am on my way to the dentist and think of the smell in the dental practice, I feel uncomfortable.
20. Before going to the dentist, I get palpitations when I think of how the dentist will be displeased at my teeth.
21. As soon as the dentist gets his/her needle ready for the anaesthetic, I shut my eyes tight.
22. In the waiting room, I sweat or freeze when I think of sitting down in the dentist's chair.
23. When I am on my way to the dentist and think that she/he will say my teeth look bad, then I want to go home again.
24. 1 already feel nervous at home when I know the dentist is going to give me an anaesthetic.
25. When the dentist's chair reclines backwards, I tell myself that the treatment will not take long.
26. In the waiting room, I feel nervous at the thought that the dentist will say my teeth are badly brushed.
27. On my way to the dentist, I get anxious at the thought that she/he will have to drill.
28. I already feel uncertain at home thinking of the moment when the dentist will look into my mouth.
29. When I am sitting in the dentist's chair not knowing what is going on in my mouth, I break into a cold sweat.
30. When I am sitting in the waiting room and thinking about the checkup, I would prefer to go home.
31. When I am on my way to the dentist and I imagine his/her instruments, my hands become clammy.
32. I think about cancelling the appointment if I suspect the dentist will be displeased at my teeth.
33. I become nervous when the dentist is about to start checking my teeth.
34. When I'm waiting for the dentist's assistant to call me in, I try to think of something else.
35. On my way to the dentist, the idea of being in the chair already makes me nervous.
36. I sleep badly the night before I have to have a tooth extracted.
Fig. 9. Dental Anxiety Inventory (DAI) [46]

categorizes patients' anxiety into three main aspects: time,

8. Revised version of Dental Belief Survey (DBS-R) [22]
situation, and response (Fig. 9). Under the time aspect,
Ten years after the development of DBS, the authors anxiety is assessed in four phases: at home, on the way
added 13 items to the original DBS and categorized them to the dental clinic, in the waiting room, and the dental
into three groups (Fig. 8). The first group, items 1 to chair. The situation aspect is divided into three categories:
11, focused on content related to professionalism or ethics. when dental anxiety starts, during interactions with the
The second group, items 12 to 20, addressed communication, dentist, and during actual dental treatment. The response
and the third group, items 21 to 28, pertained to the feeling aspect comprises emotional, physiological, and cognitive
of control. However, the modified version, known as DBS-R, responses. To create a comprehensive assessment, 36
was rarely used [21]. The response system employed a questions were formulated by combining one question
five-point response scale, similar to the one used in DBS. from each aspect: time (4) x situation (3) x response (3).
Responses were collected using a 5-point likert-type
9. Dental Anxiety Inventory (DAI) [6]
scale, with "complete disagreement" scored as 1 and
The DAI, developed in the Netherlands in 1993, "complete agreement" scored as 5. The overall level of

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 Dental Anxiety Scale

Short Dental Anxiety Inventory (SDAI)

Instructions
This questionnaire consists of nine statements that are related to the dentist. Would you please indicate for each statement to what extent it applies
to you personally?
You may not have been in the given situation before. In that case, please try to imagine the situation as best as you can and indicate what your
reaction would be. Indicate for each statement the number belonging to the answer which matches your feelings best.
1--------- ---------2--------- ---------3--------- ---------4--------- --------5
Totally untrue Hardly true Partly true Quite true Completely true
1. I become nervous when the dentist invites me to sit down in the chair. 1—2—3—4—5
2. When I know the dentist is going to extract a tooth I am already afraid in the waiting room. 1—2—3—4—5
3. When I think of the sound of the drilling machine on my way to the dentist, I would rather go back. 1—2—3—4—5
4. I want to walk out of the waiting room the moment I think the dentist will not explain what she is going to do in my mouth. 1—2—3—4—5
5. As soon as the dentist gets his/her needle ready for the anaesthetic, I shut my eyes tight. 1—2—3—4—5
6. In the waiting room, I sweat or freeze when I think of sitting down in the dentist’s chair. 1—2—3—4—5
7. On my way to the dentist, I get anxious at the thought that she will have to drill. 1—2—3—4—5
8. When I am sitting in the dentist’s chair not knowing what is going on in my mouth, I break in a cold sweat. 1—2—3—4—5
9. On my way to the dentist, the idea of being in the chair already makes me nervous. 1—2—3—4—5
Fig. 10. Shortened version of Dental Anxiety Inventory (SDAI) [6]

Dental Cognitions Questionnaire (DCQ)

Beliefs about oneself and dentistry in general
1. Dentists do as they please 8. My teeth can't be saved
2. Dentists are often impatient 9. I should be ashamed about my teeth
3. The dentist does not care if it hurts 10. My teeth might break
4. Dentists do not understand you 11. I can't stand pain
5. Dentists are often incapable 12. I am a tense person
6. Dentists think you act childish 13. I am a difficult person
7. Treatments often fail 14. l am someone with very long roots
Self-statements during treatment
15. Everything goes wrong 27. have no control over what happens
16. This treatment will hurt 28. will die during treatment
17. My teeth will break 29. will panic daring treatment
18. Something surely will go wrong 30. will faint during treatment
19. It never runs smoothly 31. will suffocate during treatment
20. I am helpless 32. can't stand this treatment for long
21. I can't control myself 33. will certainly have pain afterwards
22. l can't escape, I'm locked in 34. The filling will certainly fall out and has to be made again
23. Anaesthetics often do not work 35. This treatment fails
24. The sound of the drill frightens me 36. I become sick
25. The dentist will drill in my tongue, gums or cheek 37. The dentist will lose control over his drill
26. The nerve will be touched 38. The dentist believes that I am a difficult patient and act childish
Fig. 11. Dental Cognitions Questionnaire (DCQ) [2]

anxiety was evaluated by summing the scores. One of the DAI, making it more suitable for clinical
drawback of the 36-item DAI is its length, which may applications (Fig. 10). The SDAI reduces the time aspect
make it less suitable for clinical applications [6]. to three phases and consists of 9 questions. Like the DAI,
Therefore, shortened versions of the DAI have also been the responses in SDAI are collected using a 5-point likert
developed to address this limitation. scale. The total score ranges from 9 to 45 points. The
interpretation of SDAI scores is as follows: scores of 9
10. The shortened version of Dental Anxiety Inventory
to 10 indicate minimal dental anxiety, 11 to 19 suggest
(SDAI) [23]
mild anxiety in specific situations, 20 to 27 imply
The SDAI was developed to overcome the limitations moderate anxiety with some self-control, and 28 to 36

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Hierarchical Anxiety Questionnaire (HAQ)

Relaxed (1) Nervous (2) Tense (3) Anxious (4) Nauseous from
anxiety (5)
How do you feel when you imagine you have to go to the dentist
tomorrow?
You are sitting in the waiting room and are waiting to be called.
How do you feel?
Imagine you are entering the room where treatment will be
provided and you can smell the typical odours.
You are lying in the dentist’s chair and the dentist enters the
room.
You and your dentist are looking at the X-rays and discussing what
work needs to be done.
How do you feel when your dentist tells you that he or she will
now clean the tartar off your teeth?
The dentist tells you that you have a cavity and that he or she
will now treat it.
The dentist changes the position of your chair and prepares an
injection.
Imagine you hear the typical sound of a dentist’s drill. How do
you feel?
The dentist tells you that the cavity is too deep and the tooth
must be removed.
One of your wisdom teeth is to be removed; the injection has
already been given. The dentist picks up the scalpel.
Fig. 12. Hierarchical Anxiety Questionnaire (HAQ) [26]

signify severe dental anxiety, making regular treatment a scale from 0% (I don't believe this thought at all) to
challenging. The correlation coefficient between DAI and 100% (I am absolutely convinced that this thought is
SDAI was found to be high, indicating a strong true).
relationship between the two scales (r = .90) [23].
13. Hierarchical Anxiety Questionnaire (HAQ in
11. Photo Anxiety Questionnaire (PAQ) [24] German HAF) [25]

The PAQ involves choosing one of five facial The HAQ, developed in Germany in 1999, consists of
expressions (1 = relaxed to 5 = very anxious) from a total of 11 questions, including six situations commonly
pictures depicting ten different situations along the known to induce anxiety in dental settings (Fig. 12). It
timeline from one month before dental treatment to the has been in used to diagnose anxiety and to differentiate
moment treatment ends. The total score ranges from 10 between anxiety and phobia. Each question is answered
to 50, and the distinctive feature is the use of pictures on a scale from "relaxed" (1 point) to "nauseous from
instead of written items for evaluation. anxiety" (5 points), and the anxiety level is calculated
by summing up the scores. Participants with scores of
12. Dental Cognitions Questionnaire (DCQ) [2]
30 or below are categorized as having low anxiety, those
Developed in the Netherlands in 1995, the DCQ with scores between 31 and 38 have a moderate level
comprises 38 questions related to negative perceptions of of anxiety, and those with scores of 38 or above are
dentists and dental care (Fig. 11). Patients respond with classified as having high anxiety. Additionally,
"Yes" (scored as 1) if they agree with the negative individuals with scores of 38 or above, who have also
perception or "No" (scored as 0) if they disagree. The avoided dental treatment for more than two years, are
total score ranges from 0 to 38. Additionally, patients are diagnosed with dental phobia [26].
asked to rate the degree of belief in each question on

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 Dental Anxiety Scale

Fear of Dental Pain Questionnaire (FDPQ)

Instruction: The items listed below describe painful dental experiences. Please look at each item and think about how FEARFUL you are of experiencing
the PAIN associated with each item. If you have never experienced the PAIN of a particular item, please answer on the basis of how FEARFUL
you expect you would be if you had such an experience. Circle one rating per item to rate your FEAR OF PAIN in relation to each event.
Item no. Translation item
1 Receiving an anesthetic in the mouth
2 Having some gum burned away
3 The dentist’s hook that gets stuck behind a filling
4 Having a lump cut open in the mouth
5 The filling of a molar
6 Receiving a root canal treatment
7 Having a tooth pulled
8 A cold sensation in the mouth close to a cavity
9 An incision in the gums
10 An old filling that’s being removed
11 Being drilled in the jawbone
12 Being drilled in a tooth
13 A cavity that’s being explored with the dentist’s hook
14 Receiving an injection in the roof of the mouth
15 Bracelets that are being tightened
16 Having a wisdom tooth extracted
17 A severe toothache.
18 A cavity that’s being excavated with a rude drill
Fig. 13. Fear of Dental Pain Questionnaire (FDPQ) [27]

Short Fear of Dental Pain Questionnaire (s-FDPQ)

Instruction:
The items listed below describe possibly painful dental procedures. Please look at each item carefully and think about how FEARFUL you are of
experiencing the PAIN associated with each item. If you have never experienced the PAIN of a particular item, please answer on the basis of
how FEARFUL you expect you would be if you had such an experience. Circle one number per item to rate your FEAR OF PAIN in relation to
each event.
Answer scale:
1--------------------------------2--------------------------------3--------------------------------4--------------------------------5
Not at all A little A fair amount Very much Extreme
Please circle one number per item to rate your FEAR OF PAIN in relation to each event.
Items Amount of fear of pain
1. Receiving an anesthetic in the mouth 1-------2-------3-------4-------5
2. Having a tooth drilled 1-------2-------3-------4-------5
3. Receiving a root canal treatment 1-------2-------3-------4-------5
4. Having a tooth pulled 1-------2-------3-------4-------5
5. Having a wisdom tooth extracted 1-------2-------3-------4-------5
Fig. 14. Short Fear of Dental Pain Questionnaire (s-FDPQ) [29]

at all" (1 point) to "extremely" (5 points). The score

14. Fear of Dental Pain Questionnaire (FDPQ) [27]
ranges from 18 to 90, focusing on fear induced by dental
The FDPQ was developed in the Netherlands in 2003 pain as its distinctive feature.
as a supplement to the FPQ-III, a general pain and fear
15. Short Fear of Dental Pain Questionnaire (s-FDPQ)
questionnaire developed in 1998 (Fig. 13) [28]. The
[29]
FDPQ aims to evaluate the relationship between pain and
fear specifically related to dental situations. The FDPQ The s-FDPQ, developed in 2006, is a shortened version
consists of 18 questions related to dental pain, and of the FDPQ, designed for easier application in clinical
participants respond on a 5-point scale ranging from "not and research settings, comprising five questions (Fig. 14).

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Index of Dental Anxiety and Fear (IDAF-4C+)

Variable Item
Dental anxiety and fear I feel anxious shortly before going to the dentist.
(IDAF-4C, 8 questions) I generally avoid going to the dentist because I find the experience unpleasant or distressing.
I get nervous or edgy about upcoming dental visits.
I think that something really bad would happen to me if I were to visit a dentist.
I feel afraid or fearful when visiting the dentist.
My heart beats faster when I go to the dentist.
I delay making appointments to go to the dentist.
I often think about all the things that might go wrong prior to going to the dentist.
Phobia Going to the dentist is actively avoided or else endured with intense fear or anxiety.
(IDAF-P, 5 questions) My fear of going to the dentist has been present for at least 6 months.
My fear, anxiety or avoidance of going to the dentist significantly affects my life in some way.
I am afraid of going to the dentist because I am concerned I may have a panic attack.
I am afraid of going to the dentist because I am generally highly self-conscious or concerned about being watched
or judged in social situations.
Stimulus Painful or uncomfortable procedures
(IDAF-S, 10 questions) Feeling embarrassed or ashamed
Not being in control of what is happening
Feeling sick, queasy or disgusted
Numbness caused by the anesthetic
Not knowing what the dentist is going to do
The cost of dental treatment
Needles or injections
Gagging or choking
Having an unsympathetic or unkind dentist
Fig. 15. Index of Dental Anxiety and Fear (IDAF-4C+) [47]

Dental Fear and Avoidance Scale

How would you rate your fear of dental treatment on the following scale?
1 2 3 4 5 6 7 8 9 10
No Moderate Extreme
fear fear fear
Rate the degree to which you avoid (for whatever reason) going to the dentist or dental hygienist?
1 2 3 4 5 6 7 8 9 10
Do not Moderate Extreme
avoid avoidance avoidance
Fig. 16. Dental Fear and Avoidance Scale (DFAS) [31]

Visual Analogue Scale for dental anxiety (VAS)

Please mark your current level of anxiety or nervousness with a cross (X) on the dotted line.
I……………………… …………………………………………………….. ………………………I
(100 mm)
Totally calm and relaxed Worst fear imaginable
Fig. 17. Visual Analogue Scale for dental anxiety (VAS) [33]

a total of 23 questions. For the IDAF-4C, respondents

16. Index of Dental Anxiety and Fear (IDAF-4C+) [30]
rate their agreement with each statement on a scale from
Developed in Australia in 2010, the IDAF-4C+ "disagree" (1) to "strongly agree" (5). The IDAF-P
questionnaire consists of three main parts: the dental requires "yes" or "no" responses, while the IDAF-S uses
anxiety and fear evaluation part (IDAF-4C), dental phobia a 5-point response scale ranging from "not at all" (1) to
part (IDAF-P), and dental stimulus part (IDAF-S) (Fig. "very much" (5). The IDAF-4C can be used indepen-
15). The IDAF-4C comprises eight items, the IDAF-P has dently and covers emotional, behavioral, physical, and
five items, and the IDAF-S contains ten items, making cognitive anxiety-related reactions.

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 Dental Anxiety Scale

Original VAS is a method that has been used since

17. Dental Fear and Avoidance Scale (DFAS) [31]
the 1920s to quantify a patient's pain [34]. To measure
Developed in Canada in 2011, the DFAS consists of dental anxiety using VAS, the question was modified to
two questions (Fig. 16). The first question assesses an "Please mark your current level of anxiety or nervousness
individual's fear of dental treatment using a ten-point with a cross (X) on the dotted line." VAS is easy to use
scale, ranging from 1 (no fear) to 10 (extreme fear). The but has the drawback of unreliable reproducibility over
second question evaluates the degree of avoidance of time [35]. However, it can be used to assess how the
dental treatment for any reason, using a ten-point scale level of anxiety changes in evolving situations [33].
ranging from 1 (do not avoid) to 10 (extreme avoidance).
3. Gatchel’s 10-point fear scale (FS) [36]

SINGLE-ITEM DENTAL ANXIETY SCALE In 1989, Gatchel introduced Gatchel's 10-point fear
scale, which allowed patients to self-assess their level of
anxiety towards dental treatment on a 10-point dental
The Single-item scale can be independently developed anxiety scale. A score of 1 represented "no fear," 5
as a scale but can also be created for one-time surveys. represented "moderate fear," and 10 represented "extreme
The first one introduced here, the Seattle Fear Survey fear." Patients were categorized into a low fear group
Item (Seattle), is part of a survey developed for telephone (scores 1-4), a moderate fear group (scores 5-7), and a
surveys in 1988, so it cannot be considered a formally high fear group (scores 8-10).
developed scale. However, it has been cited in other studies
4. Dental Anxiety Question (DAQ) [37]
for comparison purposes; hence it is included for reference.
VAS, Gatchel’s 10-point fear scale, and DAQ (Dental In 1990, DAQ was introduced by Neverlien from
Anxiety Question) are dental anxiety scales composed of Norway, which is a single-item scale that assesses dental
single-item questions. Single-item question scales are anxiety with the question "Are you afraid of going to
commonly used in large-scale surveys due to their ease the dentist?" with response options: 1) No, 2) A little,
of use, but they have the drawback of potentially being 3) Yes, quite, and 4) Yes, very.
perceived as ambiguous by patients, and their interpretations
can also be somewhat unclear [16]. In addition, there is DISCUSSION
a limitation that the patient's response may vary depending
on the situation or time.
The most significant influence on a patient's subsequent
1. Seattle fear survey item (Seattle, US) [32]
behavior (such as whether or not they avoid getting dental
In the 1988 US telephone survey, participants were asked treatment) is the patient's subjective experience of the
the question, "How do you rate your own feelings toward procedure [38]. Anxiety and fear towards dentistry can
dental treatment?" and were given a 5-point scale to respond, stem from various factors, including general uncertainty,
ranging from 1 (not at all afraid) to 5 (terrified). Those who influence from others' experiences, and personal
answered somewhat afraid/very afraid/terrified were classified encounters. Dentists should not overlook the possibility
as the high-fear group, while those who answered not at all that their treatment may contribute to the development
afraid/a little afraid were classified as the low-fear group. of pathological dental phobia. Due to the subjective and
ambiguous nature of anxiety and fear, various scales have
2. Visual Analogue Scale for dental anxiety (VAS)
been developed over time to assess and measure them.
(Fig. 17) [33]
The nature of dental anxiety is multi-component [6].

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Table 1. Dental anxiety or fear scale

Title Year Country Items Response Scoring methods and Characteristics Strengths Weaknesses
cut off point
Corah Dental 1969 US 4 Five point scale Sum (4-20) To the best of our knowledge, it is Relatively concise DAS does not address the
Anxiety Scale 4=no fear the first scale for dental anxiety. evaluation method. relationship between
(DAS) [7] 5-8=low fear Most commonly used internationally dentists and patients with
9-14=moderate fear in dentistry. DAF.
15-20=high fear DAS does not adequately
capture the multifaceted
nature of DAS.
Modified Dental 1995 UK 5 Five point scale Sum (5-25) Developed by modifying Corah's Dental An item assessing the Same as DAS
Anxiety Scale 1=Not anxious Anxiety Scale (DAS) patient's mood during local
(MDAS) [12] 2=Slightly anxious anesthesia was added to
3=Fairly anxious Corah's DAS, and the
4=Very anxious response options were
5=Extremely simplified.
anxious
Gale’s Ranking 1972 US 29 Ranking RQ is composed of 3 part. Parts 2 It is meaningful in terms of Considering only Part 2, it
Questionnaire and 3 evaluate DAF. The second part identifying factors that is no different from a
(RQ) [13] is a single item, rating the patient's cause anxiety in the patient.
single-item scale.
anxiety level, and the third part consists In Part 3, there was little
of 25 items. Patients are asked to rank difference in the ranking of
25 possible dental situations in order dental anxiety provoking
from most to least fearful. factors between the high and
low dental anxiety groups.
Therefore, it cannot be used
to assess the patient's
anxiety level.
Dental Fear Survey 1973 US 27 Five point rating Two questions on behavioral There’s no items about the
(DFS) [14] 1 or 2; low fear responses (dental cognitive and affective
4 or 5; high fear avoidance) and five reaction.
questions on physiological Thedentist'sremarksandther
responses are included in elationshipwithpatientsaren
the questionnaire. otincluded.
There is no standardized
instruction and no norm data
is provided.
Modified Dental Fear 1984 US 20 Five point rating The part that asked about the anxiety
Survey in 20 items level of the patient's acquaintances
(MDFS) [16] was removed.
Dental state anxiety 1982 US 20 Four point scale A variant of the STAI (State-Trait Emphasis on the
scale 1=not at all Anxiety Inventory) often used by psychological aspect of
(DSAS) [17] 4=very much psychologists to assess people's anxiety itself
anxiety levels
Dental Belief Survey 1985 US 15 Five point likert scale Focus on the anxiety evoked in relation
(DBS) [19] to the dentist
Revised version of 1995 US 28 Five point likert scale Sum Ten years after the presentation of the However, this new version
Dental Belief Survey 28 (highly positive) - 140 DBS, the authors modified the scale has not been used in other
(DBS-R) [22] (highly negative) and added 13 items. research centres.
Dental Anxiety 1993 Nethe- 36 Five point likert scale Sum (range 36 to 180) Facet approach A drawback of the facet
Inventory rlands (1) "I totally -A time facet A with four elements design is that this method
(DAI) [6] disagree" to (a1 in the dental chair>a2 in the leads to rather lengthy
(5) "I totally agree" waiting room>a3 on the way to the questionnaires. The DAI is
dentist>a4 at home) therefore not primarily
-A situation facet B with three elements appropriate for dental
(b1 introductory aspects of dental offices.
anxiety=b2 [professional] interaction
between dentist and patient<b3
actual dental treatment)
-A reaction facet C with three elements
(c1 emotional feelings>c2 physical
reactions=c3 cognitive reactions)

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 Dental Anxiety Scale

(continued)
Title Year Country Items Response Scoring methods and Characteristics Strengths Weaknesses
cut off point
Shortened version of 1993 Nethe- 9 Five point likert scale Sum (range 9 to 36) The time facet was reduced to three
the DAI rlands 9-10; patient is hardly or not at all levels.
(SDAI) [23] anxious for dental treatment
11-19; patient is somewhat anxious,
or experiences anxiety for only a
specific aspect of the dental
treatment
20-27; patent is anxious and tense,
but is able to control his or her anxiety
during treatment
28-36; patient is extremely anxious
and unable to undergo normal dental
treatment
Photo Anxiety 1993 Nethe- 10 Five point rating Sum of all ratings (range 10-50) The non-verbal response scale
Questionnaire rlands (1=relaxed to includes five images of
(PAQ) [24] 5=very anxious) different-looking people.
Anxiety scores are ordered
chronologically from one month prior
to dental treatment to immediately
following dental treatment.
Dental Cognitions 1995 Nethe- 38 yes(1)/no(0) "Yes"-responses on the items are 38 negative cognitions (beliefs and
Questionnaire rlands summed self-statements) concerning dental
(DCQ) [2] Total negative cognition score care
(range 0-38) - The first section of the questionnaire
provides a list of 14 negative
presumptions about the patient and
dentistry in general
- 24 unfavorable remarks about
oneself that relate to how one thinks
while receiving treatment make up
the second segment.
Hierarchical Anxiety 1999 Germany 11 Five levels of anxiety Sum (range 11-55) Primary German instrument to screen
Questionnaire -From relaxed (1 The patients are divided into three patients with anxiety or even phobia
(HAQ) [25] points) groups: Contains six treatment situations that
-To anxious to the - Group 1 low level of anxiety to 30 illustrate the circumstances that
point of feeling ill (5 points cause patients to become anxious
points) - Group 2 medium level of anxiety the most frequently.
from 31 to 38 points
- Group 3 high level of anxiety>38
points
Fear of Dental Pain 2003 Nethe- 18 Five-point Sum (range 18-90) It focused on fear derived from 5-min. to complete the
questionnaire rlands Likert-type scale pain-related experiences. questionnaire
(FDPQ) [27] 1. notatall
2. alittle
3. afairamount
4. verymuch
5. Extremely
Short Fear of Dental 2006 Nethe- 5 Five point likert scale Sum (range 5-25)
Pain Questionnaire rlands disagree (1) to
(s-FDPQ) [29] strongly agree (5)
Index of Dental 2010 Australia 23 Five point likert scale Contains 3 modules that measure
Anxiety and Fear From disagree (1) to DAF, dental phobia, and feared dental
(IDAF-4C＋) [30] strongly agree (5) stimuli
- 'C' for four components: emotional,
behavioral, physiological, and
cognitive
- '+' for the added modules: phobia
(IDAF-P) and stimulus (IDAF-S)
modules

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(continued)
Title Year Country Items Response Scoring methods and Characteristics Strengths Weaknesses
cut off point
Dental Fear and 2011 Canada 2 Ten point rating scale Subjects who scored 4 or less Designed to assess both Simple, easy to administer
Avoidance scale 1 (no fear/avoidance) out of 10 ; low or normal level cognitive and behavioural screening tool that asks
(DFAS) [31] 5 (moderate fear/ of fear or avoidance dimensions of dental anxiety to subjects to separately rate
avoidance) Scores of 5 or higher reflected distinguish individuals with their degree of fear and
10 (extreme fear/ individuals with moderate to normal anxiety from those with avoidance related to dental
avoidance) extreme anxiety, a pathological or clinically treatment
corresponding to a clinically significant level of dental
significant level of dental anxiety.
anxiety
Single item
Visual analog scale 1988 US 1 10 centimeter Left end means "totally calm Single-item surveys were It can only convey the whole
(VAS) for dental and relaxed" employed in surveys aimed feeling of dental anxiety or
anxiety [33] Right end means "Worst fear at large populations one specific component.
imaginable" primarily for the
Seattle fear survey 1988 US 1 Five point scale High-fear category convenience of research.
item - Not at all afraid - Somewhat afraid
(Seattle) [32] - A little afraid - Very afraid
- Somewhat afraid - Terrified
- Very afraid Low-fear category
- Terrified - Not at all afraid
- A little afraid
Gatchel’s 10-Point 1989 US 1 Ten point scale 1-4 = low fear
Fear Scale 1 represented “nofear” 5-7 = moderate fear
(FS) [36] 5 represented 8-10 = high fear
“moderate fear”
10 represented
“extreme fear”
Single-item Dental 1990 Norway 1 Four alternative 1 No
Anxiety Question answers 2 A little
(DAQ) [37] 3 Yes, quite
4 Yes, very

When researching the history of dentistry, we can easily could be considered the "right" answer. However, upon
find numerous pictures that depict dentists as devils or gathering and examining all the scales in one place, I
portray the fear associated with dental treatment even came to the realization that each scale approaches DAF
before the academic development of dentistry [39]. with its own set of criteria and perspectives. This is
Through these images, we can understand that patients fundamentally because DAF is an intangible concept,
already had a significant fear of dental treatment even which cannot be easily grasped or measured directly. As
before dental anxiety was quantified. This can be a result, it takes on a multicomponent nature, as it is
attributed to various factors that acted in combination, expressed in various ways and through different
such as pain, the proximity of the oral cavity to the head, components. In other words, DSAS aimed to understand
the visual fear associated with metallic instruments, the DAF based on the patient's sensations and experiences,
enduring auditory fear throughout the treatment, and the while DBS focused on the doctor-patient relationship.
tactile discomfort when instruments touch the teeth. DCQ placed greater emphasis on the cognitive aspects
According to this review, the development of dental related to dentistry, and FDPQ concentrated on the fear
anxiety scales has been ongoing since 1969 and continues induced by pain. HAQ primarily focused on situations
to the present day (Table 1). Before conducting a review known to trigger DAF in dentistry. Of course, there are
of the numerous DAF scales, I believed that there was also scales that aim to comprehensively evaluate the
no perfect scale and, therefore, no definitive scale that multicomponent aspects of DAF. Despite some limi-

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 Dental Anxiety Scale

tations, DAS, which is widely cited today, also aims to in the Seattle item and 95% of respondents who answered
understand DAF from multiple angles. Similarly, DAI “very much” and “much” afraid in the DFS item
considered temporal aspects, situational aspects, and answered DAS scores “≥15”. On the other hand, only
reactive aspects in order to understand DAF. In the case 34% and 50% of those who responded “somewhat afraid”
of DFS, it aimed to assess various aspects related to DAF to the Seattle and DFS items, respectively, were the same
in patients. This includes behavioral aspects such as as the subjects who answered DAS 14-12. These results
avoidance, which is commonly observed in highly showed somewhat different concordance according to the
anxious patients. Additionally, DFS evaluated the degree of anxiety.
physiological changes associated with anxiety and In a study targeting the Toronto population in Canada,
identified the dental stimuli that trigger these changes. when DAS, Seattle item, and FS were compared in the
IDAF-4C also comprehensively assesses emotional, same subject, Spearman rank correlation coefficients
physiological, behavioral, and cognitive changes between the three measures were all high and significant.
triggered by anxiety. It includes separate sections to (DAS vs Seattle; 0.78, DAS vs FS; 0.77, Seattle vs FS;
provide additional evaluation for patients displaying 0.74). However, the kappa values reveal rather low
dental phobia (IDAF-P) and for assessing dental stimuli (DAS-Seattle; 0.48, DAS-FS ; 0.56, Seattle-FS ; 0.37).
that induce DAF (IDAF-S). The number of items in the Therefore it was concluded that there is no gold standard
scales varies from 1 to 38, and responses are of dental anxiety scale [42]. This is because the
predominantly measured using a 4-5 point likert scale. emotional/physiologic/behavioral/cognitive response of
The scores for each item are aggregated to quantify the anxiety reflected in the questions for each scale is
level of patient anxiety. The development of numerous different, and as a result, patients' answers vary, which
dental anxiety scales can be seen as a series of processes can lead to differences in prevalence [43,44].
in which dentists show interest in patients' DAF. When While developing IDAF-4C+, Pearson's r correlation
dentists demonstrate concern for patients' DAF, it is with DAS and single-item dental fear (asked about the
possible that patients' DAF may be alleviated even to amount of fear or distress that would be felt if the person
some extent. were to go to a dentist now) was obtained (IDAF-DAS;
When talking about the prevalence of DAF, it cannot 0.84, IDAF-single item; 0.57, DAS-single item; 0.58)
be denied that there are, of course, cultural and racial [30].
differences. However, it is difficult to directly compare Another problem is the criterion of the cut-off point
results obtained using different measurement scales. is presented differently for each scale, and accordingly,
There are studies comparing results using different scales the prevalence may be measured more or less [42].
in the same population. When the prevalence of DAF was However, dental anxiety is a continuous concept, and it
investigated using FS and DAS among adults in large is a very important issue where to place the cut-off point
cities in Sweden, the correlation between the two was in a study to compare people with and without anxiety.
0.81 (the same subject answered each of the two scales) Therefore, it is good to investigate the patient's anxiety
[40]. level using multiple scales and consider whether the
The results of comparing DAS, summary item of DFS patient shows emotional/physiologic/behavioral/cognitive
(“In general, how fearful are you of having dental work responses due to anxiety [42], among the scales
done?”), and Seattle fear survey items for Danish adults developed later, all of these characteristics of anxiety are
were DAS-DFS (rs = 0.72), DAS-Seattle (rs = 0.68), and included in the scale [30]. However, some of these scales
DFS-Seattle (rs = 0.78) [41]. However, 78% of have the disadvantage of being somewhat complicated for
respondents who answered “terrified” and “very afraid” clinical application, and a short version is also released

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separately. management. Edited by, Elsevier Health Sciences. 2017.

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