ANXIETY AND PAIN MEASURES IN

DENTISTRY: A GUIDE TO THEIR

QUALITY AND APPLICATION
J. TIMOTHY NEWTON and DAVE J. BUCK
J Am Dent Assoc 2000;131;1449-1457

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CLINICAL

PRACTICE

ANXIETY AND PAIN MEASURES IN DENTISTRY:

A GUIDE TO THEIR QUALITY AND APPLICATION
J. TIMOTHY NEWTON, PH.D.; DAVE J. BUCK, M.SC.(ECON.)

Background. The authors review measures

of anxiety and pain used in recent dental studies. In
particular, the study identifies the reliability, validity and usefulness of the measures.
Type of Studies Reviewed.
Three computerized databases of published scientific
literature were searched over a 10-year period. Only
studies that included measures of anxiety or pain
were included.
Results. Information on the reliability and
validity of 15 measures of dental care anxiety and

The behavioral sciences have become an

increasingly important component of dental education and research.1,2 One component of this has
been the application of psychological methods to
the study of behavior and attitudes relevant to
health, illness and health carein particular,
fear of dentists and dentistry as well as of dental
pain. This has included a wide range of methodological approaches and techniques, especially
the use of questionnaires and behavioral measures. Several authors have emphasized the
importance of ensuring that such measures are
reliable, valid and applicable to the population
toward which they are aimed.3,4 We seek to provide an overview of measures of anxiety and pain
in dental research during a 10-year period and
an appraisal of the psychometric properties of
the measures used. We hope that this will serve
two functions: to help researchers choose suitable
measures when undertaking studies of behavior
in dentistry, and to identify areas in which

three measures of pain and pain-related behaviors is

provided. Reliability and validity data for most
measures are good. Corahs Dental Anxiety Scale is
the most widely used measure of anxiety, although it
may not be as sensitive as other measures. The
McGill Pain Questionnaire is the measure of choice
for the assessment of pain.
Clinical Implications. The authors
have summarized properties of the scales for clinicians and researchers planning to use measures of
anxiety, measures of pain, or both.

researchers might work to develop new psychometrically robust measures.

Fear of dentists and dentistry is a common
and potentially distressing problem, both for the
public and for dental practitioners. The most
recent adult dental health survey conducted in
the United Kingdom found that about 25 percent
of adults are sufficiently fearful of dentistry to
avoid or delay attendance.5 To date, there has
been no comprehensive published review of the
measures of anxiety used in dental research.
Although Schuurs and Hoogstraten6 compared
six measures of dental anxiety, they excluded
measures that have been used with children, and
made no attempt to determine the extent to
which scales had been adopted for use by researchers. Locker and colleagues7 did make a
direct comparison of three questionnaire measures of adult dental anxiety in a Canadian population. However, theirs was not a comprehensive
review of available measures. Similarly, there is

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CLINICAL PRACTICE
little published evidence on
which to compare the utility
of measures of pain in dental
settings.
MATERIALS AND
METHODS

1450

The use of
questionnaire
measures of anxiety
in dentistry is wellestablished.
bility and validity, the terms
satisfactory and high are
used to refer to the following
criteria. For internal consistency, measured by Cronbachs ,
satisfactory is used when the
value of is greater than .60;
high is used when is greater
than .80. For test-retest correlations, a value of r > .80 is
rated as satisfactory and a
value of r > .90 as high. For
interscale correlations used to
determine the validity of a
scale, r > .60 is considered satisfactory and r > .80 is considered high.
RESULTS

Measures of dental anxiety.

We identified a total of 15 measures used to measure dental

anxiety. These can be subdivided into the following categories:

specific measures of dental care
anxiety in adults, specific measures of dental anxiety in children and general measures of
anxiety that have been used in
the dental setting. The use of
questionnaire measures of anxiety in dentistry is wellestablished, as evidenced by the
number of articles identified.
Table 1 provides a summary of
the measures identified.
Adult dental scales.
Corahs Dental Anxiety Scale.9
Corahs Dental Anxiety Scale,
or DAS, is a four-item measure.
Respondents are asked about
four dentally related situations
and are asked to indicate which
of four responses (of increasing
severity) is closest to their likely response to that situation.
The scale yields a score of 4 to
20, with high scores indicating
greater anxiety. Scores greater
than 15 are indicative of phobic
levels of anxiety.10 The scale
has been used for adults and
children.11,12 The internal consistency and test-retest reliability of the scale are high.10
Alternate versions of the scale
are available in three European
languages.13-15
Corahs DAS has been modified by the addition of a fifth
item that asks about responses
to administration of local anesthetic and by a change in the
response format.16 The modified
scale has high levels of reliability and validity. Mean scores
are provided for phobic and
nonphobic patients. Corahs
DAS is widely used, but has
been criticized as exhibiting a
range of total scores that is too
narrow to be used effectively in
clinical studies6; by increasing
the number of possible responses from four to five and by

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We performed computerized
searches of the dental literature
published in a 10-year period to
identify all studies in which
questionnaire measures of psychological constructs had been
included. We reviewed the articles to identify the scales that
had been used. We then examined the primary sources to
identify the psychometric
properties of the measures
identified.
Search strategy. A complete description of the search
mechanism used is found elsewhere.8 We searched the MEDLINE, EMBASE and SSCI
databases for a 10-year period
from July 1988 through June
1998. For the purposes of this
article, only studies that included measures of anxiety or pain
will be revieweda total of 43
reports. We identified a total of
15 questionnaires in 38 articles
that measured dental anxiety
and three questionnaires in
eight articles that measured
dental pain and pain behaviors.
Data gathered. We gathered specific information on
each scaleinsofar as it was
possibleusually from sources
referenced in the articles. Articles, books and other materials
containing this information that
were published before our review period were included to
obtain a complete picture of the
qualities of the scale. Furthermore, cited articles were not
restricted to the dental literature and included research in
medicine and psychology.
The information we collected

on each scale was as follows:

dthe length of the scale (that
is, the number of questions);
dresponse format(s) used;
ddata on the reliability of the
scale;
ddata on the validity of the
scale;
davailability of alternate
forms of the scale.
For some scales, we were
unable to obtain complete information; in some cases, the
authors had not assessed a particular property of the scale (for
example, alternate forms of the
questionnaire) or the evidence
was published in a source that
was not readily available (for
example, a doctoral thesis). In
the descriptions of scale relia-

CLINICAL PRACTICE
TABLE 1

MEASURES OF DENTAL ANXIETY.

SCALE

NUMBER OF ARTICLES IN
WHICH SCALE IS CITED
(N = 38)*
Adult Dental Scales

Corahs Dental
Anxiety Scale9

35

Modified Dental
Anxiety Scale16

Kleinknechts
Dental Fear
Survey17

Dental Anxiety
Question19

Gatchels
10-Point Fear
Scale22

Photo Anxiety
Questionnaire23

Dental Anxiety
Inventory25

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introducing an additional item,

the modified DAS helps to rectify this problem.
Kleinknechts Dental Fear
Survey.17 Kleinknechts Dental
Fear Survey asks respondents
to rate their anxieties about 27
specific situationssuch as
making an appointment or
hearing the dental drillon a
five-point Likert scale ranging
from none to great. Three
dimensions of the questionnaire
have been derived from factor
analysis: avoidance of dental
treatment, somatic symptoms
of anxiety and anxiety caused
by dental stimuli. These factors
are reliable and stable across
different groups of respondents.18 Data are available on
the internal consistency of the
scale, test-retest reliability and
validity of the questionnaire,
all of which are satisfactory.
Dental Anxiety Question.19
The Dental Anxiety Question,
or DAQ, is a single-item construct: Are you afraid of going
to the dentist? It has four possible responses: no, a little,
yes, quite, yes, very. These
responses are scored from 1 to
4 in the direction of increasing
anxiety. This question also has
been used with a five-point
response scale.7,20 The DAQ correlates well with Corahs DAS
(r > .71 in studies of adult and
child populations7,14,19). Singleitem inventories have been
regarded with skepticism by
scale developers because they
do not provide opportunities to
control for response-set bias
(such as the tendency to give
responses that the participant
believes are correct), and
because they do not allow for
the isolation of components of
multidimensional constructs.
However, for some purposes,
such as screening people who

Childrens Dental Scales

Childrens Fear
Survey Schedule26

Venham Picture
Scale29

Venham Anxiety
and Behavior
Rating Scales30

Adolescents
Fear of Dental
Treatment
Cognitive
Inventory32

Behavior
Profile Rating
Scale33

General Adult Scales

Spielbergers
State-Trait
Anxiety
Inventory34

Fear Survey
Schedule36

Weiner Fear
Questionnaire40

* During the period from 1988 through 1998. The total is greater than 38 since studies
used more than one measure of dental anxiety.

are likely to be highly anxious

about dental treatment, it is a
useful and brief tool,21 although

it has a tendency to overestimate the prevalence of severe

dental anxiety.7

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1451

CLINICAL PRACTICE

1452

phrases do not arise, andprovided that the facial expressions depicted are universal
difficulties in translating
responses do not arise. De
Jongh and Stouthard24 used
this scale to analyze the degree
of anxiety experienced by
patients receiving treatment
from a dental hygienist.
Dental Anxiety Inventory.25
The Dental Anxiety Inventory,
or DAI, is a 36-item scale.
Answers are given on a fivepoint scale, and scores range
from 36 (no anxiety) to 180
(high anxiety). The internal
consistency of the scale is high
( = .95 for a student popula-

There are potential

advantages to a
response format that
does not rely on
verbal markers:
problems of
differences in the
interpretation of
words and phrases
do not arise.
tion, and .98 for a general population sample). The test-retest
correlation during a two-week
period also was satisfactory
(r = .87). The scale correlates
with Corahs DAS (r = .87),
although the factorial validity
of the scale is unsatisfactory.
The data did not fit well with
either a three- or four-factor
solution. Schuurs and Hoogstraten6 concluded that the
validity of the DAI must still be
determined.
Scales for children and
adolescents. Childrens Fear
Survey Schedule.26 The Childrens Fear Survey Schedule, or

CFSS, is designed to assess a

range of general fears in children. A dental subscale has
been devised (CFSS-DS27) that
consists of 15 items rated on a
five-point scale, ranging from 1
(not afraid) to 5 (very afraid).
Scale scores are calculated by
summing item scores; the total
score can range from 15 to 75.
Scores above 38 indicate significant dental fear.28 Both the fullscale and dental subscale are
internally consistent.26,27 The
CFSS-DS has been found to
disciminate between children
who do and do not display dental fear and behavioral problems during dental treatment.28
Venham Picture Scale.29 This
scale consists of a series of
eight paired drawings of a
child. Each pair consists of a
child in a nonfearful pose and a
fearful pose (for example, running away). The respondent is
asked to indicate, for each pair,
which picture more accurately
reflects his or her feelings at
the time. Scores are determined
by summing the number of
instances in which the child
selects the high-fear stimulus.
To our knowledge, there is no
published information about
the reliability and validity of
the scale.
Venham Anxiety and
Behavior Rating Scales.30 These
two scales assess the anxiety
and uncooperative behavior of
children in the dental setting.
Both scales consist of five behaviorally defined categories
ranging from 0 to 5, with higher
scores indicating greater levels
of anxiety or lack of cooperation. The criteria used to assign
the scores are described by
Venham and colleagues.30 Using
the method of paired comparisons, they were able to ascertain that the points on the scale

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Gatchels 10-Point Fear

Scale.22 This is a single-item
scale that asks respondents to
rate their dental fear on a 10point scale. A score of 1 indicates no dental fear; 5, moderate fear; and 10, extreme fear.
A score of 8 or greater is considered to indicate a significant
degree of anxiety; approximately 11 percent of a North
American sample scored at this
level.22 Agreement between the
Gatchel scale and Corahs DAS
in the identification of people
with significant dental fear is
only moderate, suggesting that
the two measures are related
but tap independent dimensions.7 The Gatchel scale reflects an overall fearfulness of
dental treatment, whereas
Corahs DAS measures a more
specific fear of the dental situation (for example, sitting in the
chair, having treatment
performed).
Photo Anxiety Questionnaire.23 This questionnaire asks
respondents to imagine they are
to undergo dental treatment
and consists of 10 items illustrating different moments before, during and after treatment. The response scale is
nonverbal, consisting of five
photographs with facial expressions of differing anxiety levels.
There are different versions for
men and women. Patients indicate which photograph best
expresses their feelings. The
scale is scored by summing the
item ratings (1 = relaxed,
5 = very anxious).
The internal consistency of
the scale is high, and it correlates well with Corahs DAS.23
There are potential advantages
to a response format that does
not rely on verbal markers:
problems of differences in the
interpretation of words and

CLINICAL PRACTICE
overall score is calculated on
the basis of the frequency of
each behavior, together with a
weighting for the severity of the
behavior (for example, kicking
is perceived to be more severe
than oral complaints). The scale
has adequate interrater reliability, given adequate training
of observers. The face validity
of the scale is high, and it has
been found to distinguish between children referred for
behavioral management of
uncooperative behavior in the
dental setting and a control
group of children.31 As with
many behavioral measures, use
of this scale is likely to be timeconsuming.

Spielbergers
State-Trait Anxiety
Inventory
distinguishes
between anxiety as
a general aspect of
personality and
anxiety as a
response to a
specific situation.
General adult scales.
Spielbergers State-Trait
Anxiety Inventory.34 Spielbergers State-Trait Anxiety
Inventory, or STAI, distinguishes between anxiety as a general
aspect of personality (trait anxiety) and anxiety as a response
to a specific situation (state
anxiety). It consists of 40 statements, 20 of which measure
trait anxiety and 20 state anxiety. Items are scored on fourpoint scales, with response categories varying according to the
nature of the question. This
questionnaire has been tested

extensively for reliability and

validity.34 A six-item version of
the state scale has been devised
that is reliable and valid and
yields scores that are similar to
those of the full version.35
Fear Survey Schedule.36 The
original Fear Survey Schedule
is a 51-item scale consisting of
a list of commonly encountered
stimuli. Each stimulus is rated
on a seven-point scale, ranging
from 0 (no fear) to 6 (terrified).
Scores indicate the extent of
general fearfulness, which
Geer,36 who developed the scale,
suggests is a personality characteristic. A shortened form (18
items) has been developed and
was used in three of the studies
identified in the literature
search.37-39 Both the full-length
and shortened scales have been
subject to extensive psychometric analyses, and both display
high levels of internal consistency and validity.36,37 Scale
scores vary between men and
women (mean scores for women
are higher). The scale has been
used in a number of European
countries, including the United
Kingdom, Norway, Sweden and
other Scandinavian countries.
Weiner Fear Questionnaire.40
The Weiner Fear Questionnairre has two parts. Part A
consists of 16 questions with a
five-point answer format seeking to reveal respondents general and dental care fears. Part
B consists of 18 questions about
autonomic stress reactions, and
has a five-point answer format;
three of the questions in this
part address severe anxiety
attacks. Few data are available
on the reliability and validity of
the scale; the only published
study using this scale was the
one for which the scale was
devised. People with significant
levels of dental care anxiety

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can be treated as interval data.

A high degree of interrater reliability was found for both
scales, even for untrained
observers. Alwin and colleagues31 found that the scale
was able to distinguish between
children referred to a specialist
treatment center for management of uncooperative behavior
in dental treatment and a control group of children.
Adolescents Fear of Dental
Treatment Cognitive Inventory.32 This scale measures the
thoughts and ideas an adolescent may have during dental
treatment. It is unique among
the childrens scales in that it
focuses solely on the cognitive
manifestations of fear. It is a
23-item scale, with a five-point
response format. Scores range
from 23 (no fear) to 115 (high
fear). The scale shows high
internal consistency ( = .91)
and moderate test-retest reliability over a one-week period
(r = .84). Factor analysis of the
scale revealed four components:
fear of pain, negative perceptions of the dentist, avoidance
of the dentist and a fourth scale
that was not interpreted by the
researchers. The scale has been
cited only in its original development study. Despite the
advantages of assessing the
cognitive dimensions of anxiety,
there is insufficient evidence to
support the usefulness of this
scale.
Behavior Profile Rating
Scale.33 This scale consists of 27
uncooperative behaviors considered to be related to dental
anxiety. The behavior of the
child in the dental setting is
observed for three-minute intervals throughout the 30-minute
consultation, and each item is
scored if the behavior occurs at
the point of observation. An

CLINICAL PRACTICE

1454

patient about his or her pain).

Using the McGill Pain Questionnaire, Beese and Morley44
found that memory in regard to
dental pain was inaccurate
over a two-week period.
The West Haven-Yale Multidimensional Pain Inventory.45
Reisine and colleagues46 used
this scale as part of a battery of
tests to compare groups of
patients receiving dental treatment with those not receiving
treatment. The scale exhibited
high levels of internal consistency ( = .87) and was found
to discriminate between these
groups. We found no other dental research studies in which
this scale has been used during
the 10-year period studied.
The Pain Anxiety Symptoms
Scale.47 This scale is not a simple measure of pain experience,
but focuses on the cognitive
aspects of pain. It consists of
three subscales: avoidance of
pain, acceptance of pain and
fear of pain. Reliability analysis of all subscales shows high
levels of internal consistency,
and the scale correlates well
with Corahs DAS. Scores within the general population are
higher for women.48
DISCUSSION

Table 2 summarizes the information about the properties of

the scales reviewed. We found
that Corahs DAS was the
measure of anxiety most widely
used. It has satisfactory reliability and validity, and is easy
to administer. However,
Schuurs and Hoogstraten6
reviewed six scales of adult
dental anxiety (including
Corahs DAS) and concluded
that the most sensitive, reliable
and valid measure was Kleinknechts Dental Fear Survey.
Given the greater range

of scores possible using this

measure, Kleinknechts Dental
Fear Survey may be a more
sensitive tool for use in
research.
Despite the number of measures reviewed and their
widespread use in dental
research, many issues in
regard to measuring anxiety
remain unresolved. Lindsay
and Jackson49 argued that
existing measures of fear of
dentistry fail to encompass new
knowledge of the factors that
contribute to dental anxiety,
particularly the role of negative
thoughtssuch as focusing on
catastrophic outcomesin the
maintenance of dental fear.
The measures surveyed are
based, for the most part, on the
physiological manifestations of
anxiety, with relatively little
emphasis placed on behavioral
and cognitive responses.
Because children may not
have a fully developed ability
to recognize and interpret the
physiological and cognitive
manifestations of anxiety,
measures of dental fear in children have tended to concentrate on the behavioral component of fear or have used nonverbal tools such as pictures.
Behavioral measures rely heavily on the training of observers
to ensure interrater reliability
and are cumbersome to apply
in practice. Pictorially based
measures such as the Venham
Picture Scale are rapidly administered, reliable and understandable to a broad age range.
While these present a potentially useful approach to the
measurement of anxiety in children, more work is necessary to
establish their reliability and
validity, as Table 2 illustrates.
General measures of anxiety
in adults are useful in that

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were included in the sample

used to develop the scale.
Measures of dental pain.
We found three questionnaires
(in eight articles) that have
been used to assess dental pain.
These are the McGill Pain
Questionnaire, the West
Haven-Yale Multidimensional
Pain Inventory and the Pain
Anxiety Symptoms Scale.
The McGill Pain Questionnaire.41 This questionnaire was
designed to assess three components of reported pain: the sensory, affective and evaluative
components. Respondents indicate the location of their current pain by marking an area
on a drawing of a human figure. They then are asked to
choose the words that best describe the pain from a list of 78
adjectives (such as flickering,
sickening). The adjectives are
grouped into 20 subclasses that
describe different aspects or
types of pain. A third part of
the questionnaire assesses
how the pain changes over time
and what relieves it or increases it. The final part is a single
measure of pain intensity.
This scale has been used in a
variety of settings for the
assessment of pain from a
variety of origins.
Grushka and Sessle42 reported that the McGill Pain Questionnaire could discriminate
between pain originating from
a reversibly inflamed tooth
pulp and pain resulting from
an irreversibly inflamed or
necrotic tooth pulp. Similarly,
Turp and colleagues43 found
that the McGill Pain Questionnaire distinguished facial pain
from other non-orodental pain.
These authors suggested that it
should be used as an adjunct to
simpler clinical assessments of
tooth pain (such as asking a

CLINICAL PRACTICE

TABLE 2

SUMMARY OF MEASURES OF ANXIETY AND PAIN.

SCALE

NO. OF
ITEMS

TARGET
POPULATION

RELIABILITY

VALIDITY

AVAILABILITY
OF NORMS
General
Population

Clinical
Population

COMMENTS

Adults

Most widely used questionnaire measure of

anxiety.

Modified Dental
Anxiety Scale

Adults

Modified version of the

Corahs, with increased
range of scores and clinical relevance.

27

Adults

Gives a score on three

dimensions: avoidance of
dental treatment, somatic
symptoms and anxiety
caused by dental stimuli.

Dental Anxiety
Question

Adults

Tends to overestimate
severe dental anxiety.

Gatchels
10-Point Fear
Scale

Adults

Photo Anxiety
Questionnaire

10

Adults

Dental Anxiety
Inventory

36

Adults

Childrens
Fear Survey
Schedule

15

Children

Venham Picture
Scale

Children

Child does not read

questions or responses.

Venham Anxiety
and Behavior
Rating Scales

Children

Two one-item scales.

Ratings made by observers on the basis of
behavior.

Adolescents
Fear of Dental
Treatment
Cognitive
Inventory

23

Adolescents

Not widely used. Addresses the cognitive

manifestations of anxiety.
Four subscales: fear of
pain, negative perceptions
of dentist, avoidance of
dentist and a fourth scale
(not interpreted).

Behavior Profile
Rating Scale

21

Children

Behavioral scale.
Resource-intensive
(requires an observer).

40 (12)

Adults

Widely used in dental and

other settings. Assesses
specific fears (state) and
general anxiety (trait).

51 (18)

Adults

Widely used scale that

assesses the extent of
general fearfulness.

Weiner Fear
Questionnaire

16

Adults

Scale not widely used.

McGill Pain
Questionnaire

11

Adults

NA

Most widely used measure

of dental pain. Found to
discriminate between pain
of different sources.

West Haven-Yale
Multidimensional Pain
Inventory

12

Adults

NA

Designed to be used in
cases of chronic pain.

Pain Anxiety
Symptoms Scale

10

Adults

Assesses cognitive aspects of pain. Three subscales: avoidance of pain,

acceptance of pain and
fear of pain.

Kleinknechts
Dental Fear
Survey

Spielbergers
State-Trait
Anxiety
Inventory
Fear Survey
Schedule

Nonverbal response
format.

: Information available.

: Information not available.

Numbers in parentheses indicate the items in the shortened form of the scale.
NA: Not applicable.

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Corahs Dental
Anxiety Scale

CLINICAL PRACTICE

1456

aspects of dental fear that are

being assessed. Longer measures (that is, those with more
questions) tend to provide a
wider range of scores and,
therefore, would be expected to
be more sensitive to change
over time or to variation between groups (for example, the
DAI or Kleinknechts Dental
Fear Survey).6
Other scales (for example,
the modified Corahs DAS) ask
respondents to rate particular
dental situations and so might
be of value in planning interventions aimed at alleviating
dental anxiety, such as systematic desensitization.51 In general, fear is expressed as changes
in thoughts, physiological state
and behavior. The scales reviewed above place different
degrees of emphasis on these
components; most scales for
adults are concerned with
thoughts, and many scales for
children are concerned with
behavior. Corahs DAS provides
a useful and short measure of
dental anxiety. It has been
used widely and extensive comparison data are available.
There are fewer scales available to assess pain. The McGill
Pain Questionnaire emerges as
a psychometrically sound measure with the ability to discriminate between pains of different
origin. It has been used widely
in both dental and medical settings. Although it may be
lengthy for use in the clinical
setting, components such as
the single-item measure of
pain intensity could be used in
isolation.
Researchers interested in
the areas of dental anxiety and
dental pain should consider
carefully the measurement of
these phenomena. Existing
measures vary widely in their

length and content. Both anxiety and pain are multidimensional constructs, and it is
important to identify which
dimensions are being assessed.
Furthermore, the use of standardized instruments provides
the opportunity for comparison
of data across groups, experimental manipulations and
treatment approaches.
CONCLUSIONS

To measure anxiety in adults

in clinical dental settings, we
recommend that Corahs DAS
be used. To measure anxiety in
adults as part of research, we
recommend Kleinknechts
Dental Fear Survey. Visual
analogue scales provide a useful measure of pain experience
for use in clinical settings. For
research purposes, however, we
recommend the McGill Pain
Questionnaire, in both complete and short forms.
Studies are needed to measure the impact of dental anxiety and dental pain on behavior
in adults. In addition, more
scales of anxiety in children are
needed that assess the cognitive manifestations of anxiety.
Finally, further research is
required to determine the reliability and validity of measures
of dental anxiety in children.
Dr. Newton is a lecturer in psychology in
relation to dentistry, Guys, Kings and St.
Thomas Dental Institute, Department of
Dental Public Health & Oral Health Services
Research, Floor 18, Guys Tower, London SE1
9RT, England, e-mail tim.newton@kcl.ac.uk.
Address reprint requests to Dr. Newton.
Mr. Buck is a lecturer in oral health economics, Guys, Kings and St. Thomas Dental
Institute, Department of Dental Public
Health & Oral Health Services Research,
London.
1. General Dental Council. The first five
years: the undergraduate dental curriculum.
London: General Dental Council; 1992.
2. Kent G, Croucher R. Achieving oral
health. Oxford, England: Wright; 1998:1-6.
3. Cacioppo JT, Tassinary LG, eds.
Principles of psychophysiology. Cambridge,

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they allow comparison of dental

anxiety with other fears. The
Spielberger measure34 has been
used widely in both dental and
nondental settings, and is
available in a short form that
could be useful in both research
and clinical settings.
Pain routinely is measured
by visual analogue scales.
Although these provide a useful
method of describing pain experience, they do not assess the
multidimensional nature of
pain. More sophisticated measures include analysis of the sensory, affective and cognitive
components of pain. In our
review, we found the McGill
Pain Questionnaire to be the
most widely used pain scale. In
a review of the literature on
pain measurement, Zakrzewska
and Feinmann50 suggested that
it is the measure of choice.
Any conclusions drawn from
this study should be tempered
by consideration of its limitations. It seems likely that some
measures have been missed in
the computerized literature
search, despite the extensive
search strategies adopted.
Furthermore, there may have
been developments in this area
of research since 1998, the last
year of our review. Still, this
report provides a fairly extensive review of the scales used to
measure anxiety, fear and pain
in dental settings.
As our review demonstrates,
there is a wide variety of measures available to assess levels
of dental anxiety. Most of them
exhibit adequate levels of internal consistency, and correlate
with other measures of the
same construct. Choice of a
particular measure will depend, in part, on the purpose
for which the measure is intended and on the particular

CLINICAL PRACTICE
20. Milgrom P, Fiset L, Melnick S,
Weinstein P. The prevalence and practice
management consequences of dental fear in a
major U.S. city. JADA 1988;116:641-7.
21. Neverlien PO. Dental anxiety, optimism-pessimism, and dental experience from
childhood to adolescence. Community Dent
Oral Epidemiol 1994;22:263-8.
22. Gatchel R. The prevalence of dental fear
and avoidance: expanded adult and recent
adolescent surveys. JADA 1989;118:591-3.
23. Stouthard ME, De Jongh A,
Hoogstraten J. Dental anxiety: the use of
photographs. Ned Tijdschr Tandheelkd
1991;98:152-5.
24. De Jongh A, Stouthard ME. Anxiety
about dental hygienist treatment. Community Dent Oral Epidemiol 1993;21:91-5.
25. Stouthard ME, Hoogstraten J. Prevalence of dental anxiety in the Netherlands.
Community Dent Oral Epidemiol 1990;18:
139-42.
26. Scherer MW, Nakamura CY. A fear survey schedule for children (FSS-FC): a factor
analytic comparison with manifest anxiety
(CMAS). Behav Res Therapy 1968;6:
173-82.
27. Cuthbert MI, Melamed BG. A screening
device: children at risk for dental fears and
management problems. ASDCJ Dent Child
1982;49:432-6.
28. Klingman A, Melamed BG, Cuthbert
MI, Hermecz DA. Effects of participant modeling on information acquisition and skill utilization. J Consult Clin Psychol 1984;52:
414-22.
29. Venham L. The effect of mothers presence on childs response to dental treatment.
ASDCJ Dent Child 1979;46:219-25.
30. Venham L, Gaulin-Kremer E, Munster
E, Bengston-Audia D, Cohan J. Interval rating scales for childrens dental anxiety and
uncooperative behavior. Paediatr Dent 1980;
2:195-202.
31. Alwin NP, Murray JJ, Britton PG. An
assessment of dental anxiety in children. Br
Dent J 1991;171:201-7.
32. Gauthier JG, Ricard S, Morin BA,
Dufour L, Brodeur J-M. La peur des traitements chez les jeunes adolescents: dveloppement et valuation dune mesure cognitive. J
Can Dent Assoc 1991;57:658-62.
33. Melamed B, Weinstein D, KatinBorland M, Hawes R. Reduction of fearrelated dental management problems with
use of filmed modeling. JADA 1975;90:822-6.
34. Spielberger C, Gorsuch R, Lushene R.
STAI manual for the State-Trait Anxiety
Inventory. Palo Alto, Calif.: Consulting
Psychologists Press; 1983.
35. Marteau T, Bekker H. The development

of a six-item short-form of the state scale of

the Spielberger State-Trait Anxiety Inventory
(STAI). Br J Clin Psychol 1992;31:301-6.
36. Geer JH. The development of a scale to
measure fear. Behav Res Therapy 1965;
3:45-53.
37. Berggren U, Carlsson SG. Usefulness of
two psychometric scales in Swedish patients
with severe dental fear. Community Dent
Oral Epidemiol 1985;13:70-4.
38. Skaret E, Raadal M, Berg E, Kvale G.
Dental anxiety among 18-year-olds in
Norway: prevalence and related factors. Eur
J Oral Sci 1998;106:835-43.
39. Locker D, Liddell AM. Correlates of
dental anxiety among older adults. J Dent
Res 1991;70:198-203.
40. Weiner AA, Sheehan DV. Etiology of
dental anxiety: psychological trauma or CNS
chemical imbalance? Gen Dent 1990;38:39-43.
41. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods.
Pain 1975;1:277-99.
42. Grushka M, Sessle B. Applicability of
the McGill Pain Questionnaire to the differentiation of toothache pain. Pain 1984;19:
49-57.
43. Turp JC, Kowalski CJ, Stohler CS. Pain
descriptors characteristics of persistent facial
pain. J Orofac Pain 1997;11:285-90.
44. Beese A, Morley S. Memory for acute
pain experience is specifically inaccurate but
generally reliable. Pain 1993;53:183-9.
45. Kerns RD, Turk DC, Rudy TE. The
West Haven-Yale Multidimensional Pain
Inventory (WHYMPI). Pain 1985;23:345-56.
46. Reisine ST, Fertig J, Weber J, Leder S.
Impact of dental conditions on patients quality of life. Community Dent Oral Epidemiol
1989;17:7-10.
47. McCracken LM, Zayfert C, Gross RT.
The Pain Anxiety Symptoms Scale: development and validation of a scale to measure
fear of pain. Pain 1992;50:67-73.
48. Liddell A, Locker D. Gender and age
differences in attitudes to dental pain and
dental control. Community Dent Oral
Epidemiol 1997;25:314-8.
49. Lindsay S, Jackson C. Fear of routine
dental treatment in adults: its nature and
management. Psychol Health 1993;8:135-54.
50. Zakrzewska JM, Feinmann C. A standard way to measure pain and psychological
morbidity in dental practice. Br Dent J
1990;169:337-9.
51. Milgrom P, Weinstein P, Getz T.
Treating fearful dental patients: a patient
management handbook. Seattle: University of
Washington; 1995.

JADA, Vol. 131, October 2000

Copyright 1998-2001 American Dental Association. All rights reserved.

1457

Downloaded from jada.ada.org on February 21, 2010

England: Cambridge University Press; 1990.

4. Schmidt LR, Schwenkmezger P,
Weinman J, Maes P, eds. Theoretical and
applied aspects of health psychology. London:
Harwood; 1990.
5. Todd J, Lader D. Adult dental health
1988, UK. London: Her Majestys Stationery
Office; 1991:242-56.
6. Schuurs A, Hoogstraten J. Appraisal of
dental anxiety and fear questionnaires: a
review. Community Dent Oral Epidemiol
1993;21:329-39.
7. Locker D, Shapiro D, Liddell A. Who is
dentally anxious? Concordance between
measures of dental anxiety. Community Dent
Oral Epidemiol 1996;24:346-50.
8. Buck D, Newton JT. Non-clinical outcome measures in dentistry: publishing
trends 1988-1998. Community Dent Oral
Epidemiol (in press).
9. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
10. Corah NL, Gale E, Illig S. Assessment
of a dental anxiety scale. JADA 1978;97:
816-9.
11. Locker D, Liddell A, Burman D. Dental
fear in an older population. Community Dent
Oral Epidemiol 1991;19:120-4.
12. Murray P, Liddell A, Donohue J. A longitudinal study of the contribution of dental
experience to dental anxiety in children
between 9 and 12 years of age. J Behav Med
1989;12:309-20.
13. Kunzelmann KH, Dunniger P. Dental
fear and pain: effect on patients perception of
the dentist. Community Dent Oral Epidemiol
1990;18:264-6.
14. Neverlien PO. Normative data for
Corahs Dental Anxiety Scale (DAS) for the
Norwegian adult population. Community
Dent Oral Epidemiol 1990;18:162.
15. Eijkman MA, Orlebeke JF. De factor
angst in de tandheelkundige situatie.
Nederlandsche Tijdschrift voor
Tandheekunde 1975;82:114-23.
16. Humphris GM, Morrisson T, Lindsay S.
The modified dental anxiety scale: validation
and United Kingdom norms. Community
Dent Health 1995;12:143-50.
17. Kleinknecht R, Klepac R, Alexander L.
Origins and characteristics of fear of dentistry. JADA 1973;86:842-8.
18. Kleinknecht R, Thorndike RM,
McGlynn FD, Harkavy J. Factor analysis of
the dental fear survey with cross-validation.
JADA 1984;108:59-61.
19. Neverlien PO, Backer Johnsen T.
Optimism-pessimism dimension and dental
anxiety in children aged 10-12 years.
Community Dent Oral Epidemiol 1991;
19:342-6.