Eur J Oral Sci 2015; 123: 453–459 Ó 2015 Eur J Oral Sci

DOI: 10.1111/eos.12229 European Journal of

Printed in Singapore. All rights reserved
Oral Sciences

Ulla Wide Boman1, Jason M.

Translation and psychometric Armfield2, Sven G. Carlsson3,
Jesper Lundgren3
properties of the Swedish version of 1
Department of Behavioral and Community
Dentistry, Institute of Odontology, The

the Index of Dental Anxiety and Fear Sahlgrenska Academy, University of

Gothenburg, Go €teborg, Sweden; 2Australian
Research Centre for Population Oral Health,

(IDAF-4C+) School of Dentistry, University of Adelaide,

Adelaide, SA, Australia; 3Department of
Psychology, University of Gothenburg,
Go€teborg, Sweden

Wide Boman U, Armfield JM, Carlsson SG, Lundgren J. Translation and

psychometric properties of the Swedish version of the Index of Dental Anxiety and
Fear (IDAF-4C+).
Eur J Oral Sci 2015; 123: 453–459. © 2015 Eur J Oral Sci
Dental anxiety (DA) is a common condition, with significant medical, psychological,
and social consequences. High-quality psychometric tools for the assessment of den-
tal anxiety are necessary for clinical and research purposes. The aim of this study
was to adapt the Index of Dental Anxiety and Fear (IDAF-4C+) to the Swedish
language and to explore the psychometric properties of the translated version. The
study included a clinical sample (n = 414; 17–91 yr of age) and a non-clinical sam-
ple (n = 51; 19–47 yr of age). The scales used were the IDAF-4C+, the Single-Ques- Ulla Wide Boman, Department of Behavioral
and Community Dentistry, Institute of
tion Assessment of Dental Anxiety (SQDA), the Dental Fear Survey (DFS), and
Odontology, The Sahlgrenska Academy,
the Internal Health Locus of Control (IHLOC). The Swedish IDAF anxiety module University of Gothenburg, PO Box 450,
showed a clear, one-dimensional structure, good internal consistency (Cronbach’s SE-405 30 Go €teborg, Sweden
alpha = 0.95), and adequate validity, as evidenced by strong correlations with the
E-mail: ulla.wide-boman@odontologi.gu.se
other DA measures (SQDA and DFS) and weak correlations with the IHLOC. In
addition, the IDAF phobia module and the IDAF stimulus module were strongly
correlated with the other DA measures. To conclude, the study shows promising Key words: adults; assessment; dental
findings for the reliability and validity of the Swedish translation of the IDAF-4C+, anxiety; psychometrics
as a useful measure of dental anxiety in research and clinical practice. Accepted for publication September 2015

Dental anxiety is a common condition, often with sig-
nificant medical, psychological, and social conse-
quences. In modern industrialized societies, most
people make regular visits to the dentist, despite dental
treatment causing some degree of anxiety in as many as
50–75% of patients (1, 2). Although most dental
patients can cope reasonably well with any form of dis-
tress resulting from treatment, for a minority of
patients, the anxiety reaches a level comparable with
that of a simple phobia, with a prevalence of 4–7% of
the population (3). There are possible differences in
meaning between the terms ‘dental fear’ and ‘dental
anxiety’; for expediency and clarity in this paper, the
term ‘dental anxiety’ is used.
Severe, phobia-like dental anxiety may have more
critical consequences than other phobias. It involves
the same level of distress when confronting the feared
object but when it leads to avoiding dental care, it may
cause severe medical effects with no obvious parallels in
other phobias. Severe dental anxiety is associated with
poor oral health, worse oral health-related quality of
life, and negative social and emotional consequences
(4–7).
High-quality psychometric tools for the assessment
of dental anxiety are necessary, for both clinical and
research purposes. Although several measures of dental
anxiety exist and are commonly used, a number of
problems have been identified with these scales, relating
to questionable or unmeasured psychometric properties,
poor relationship with theory, and the absence of
important aspects of dental anxiety (8, 9). A new scale
to measure dental anxiety and fear is the Index of Den-
tal Anxiety and Fear (IDAF-4C+) (8). The IDAF-4C+
is based on psychological theory on emotions, and
includes three modules to make it a flexible instrument
for various uses in epidemiological research, clinical
research, and clinical practice. Promising findings have
been reported on the reliability and validity of the
IDAF-4C+ in a representative sample of adults in an
epidemiological Australian study (8), as well as for nor-
mative data (10). The IDAF-4C+ has been translated
into a number of languages, including Spanish (11) and
German (12). Following these promising findings, there
is a need to make further adaptations and evaluations
of the scale in other countries. Moreover, until now,
the scale has not been tested on clinical samples.
For research purposes, it is important to compare
results on dental anxiety between different cultures and
countries. It is also crucial to have an instrument that
mirrors all aspects of dental anxiety that are known
454 Wide Boman et al.

today. However, when translating and adapting a psy- Non-clinical sample

chometric measure from one language to another, some
precautions need to be observed in order to acquire the
same measurement properties in the translated and the
original versions (13).
The aim of this study was to adapt the IDAF-4C+
to the Swedish language and to explore the psychomet-
ric properties of the translated version when used on
clinical and non-clinical samples of adult individuals.
Material and methods
Clinical sample
The clinical sample consisted of a consecutive sample of
regular dental patients attending a public dental health
clinic specialized in dental surgery. Patients who accepted
inclusion in the study answered the questions on a touch
pad, while sitting in the waiting room. The aim of this
arrangement was to furnish the dental team with ‘on-line’
information about the degree and nature of the patients’
dental anxiety. The clinical sample consisted of 414 partici-
pants (17–91 yr of age) (Table 1). All participants in the
clinical sample answered questions on age and gender, the
single question on dental anxiety (SQDA), and the first
module (the anxiety and fear module) of the IDAF-4C+.
They were also asked whether they knew what was going
to be done during the appointment. Those indicating at
least a minimum degree of dental anxiety continued with
the second and third modules of the IDAF scale. For the
purposes of this study, a minimum degree of dental anxi-
ety was defined as reporting anxiety on at least one of the
items on the fear and anxiety module (a score of 2 or
higher), and reporting at least ‘A little’ dental anxiety on
the single-question assessment of dental anxiety. Of the
414 patients, 153 reported no sign of dental anxiety at all;
consequently, the remaining 261 filled in the second and
third modules of the IDAF-4C+.
The non-clinical sample consisted of postgraduate univer-
sity students. The students attended different postgraduate
courses at the University of Gothenburg and were invited
to participate in the study voluntarily in conjunction with
a lecture. The questionnaires were answered anonymously.
The sample consisted of 51 participants (19–47 yr of age)
(Table 1). These participants answered questions on age
and gender, and were tested with the IDAF-4C+ and two
other scales – the Dental Fear Survey (DFS) (14) and the
Internal Health Locus of Control (IHLOC) scale from the
Multidimensional Health Locus of Control scale (15).
As no personal information about the patients was
gathered and no interventions were included, the study
was not subject to the Swedish Ethical Review Act and
was therefore not subjected to a formal process of
approval. However, the clinical sample was part of a pilot
study, the main study of which was approved by the
Regional Ethical Review Board of Link€ oping (Dnr: 213-
233-31).
Translation procedure of the IDAF-4C+
Three Swedish psychologists (co-authors U.W.B., J.L.,
and S.G.C.), with theoretical as well as clinical expertise in
dental anxiety and phobia, independently translated the
original scale into Swedish. Detailed discussions on dis-
crepancies between the three translations resulted in a pre-
liminary Swedish version, which was translated back into
English by a professional translator. Comparisons between
the original scale and the back translation showed a few
discrepancies that were adjusted by rephrasing the Swedish
wording, and the appropriateness of the corrections was
checked by repeating the back translation. At this stage,
we also made a face validity check by administering the
Swedish version of the scale to a small number of patients
with dental anxiety. There was a positive judgment regard-
ing the comprehensibility of the scale; however, following
patient remarks, it was decided to make a few, minor,

Table 1
Study characteristics: gender, age, Index of Dental Anxiety and Fear (four-components module) (IDAF-4C; clinical and non-clinical
samples), Dental Fear Survey (DFS) (non-clinical sample), and Internal Health Locus of Control (IHLOC) (non-clinical sample)

Clinical sample Non-clinical sample

Total Male Female Total Male Female
n 414 232 182 51 16 35

Age (yr) 50 (17–91) 52 (17–91) 50 (18–86) 26.2 (19–47) 29 (22–47) 24 (19–44)*

† † †
DFS 33.98 (12.80) 31.69 (9.04) 35.03 (14.20)
IDAF-4C 1.60 (0.9) 1.44 (0.76) 1.73 (1.02)** 1.60 (0.7) 1.57 (0.64) 1.61 (0.80)
IDAF-4C-E 1.78 (1.10) 1.58 (0.91) 1.94 (1.20)** 1.73 (1.01) 1.50 (0.58) 1.83 (1.15)
IDAF-4C-C 1.40 (0.84) 1.28 (0.69) 1.49 (0.94)** 1.31 (0.62) 1.31 (0.66) 1.31 (0.61)
IDAF-4C-B 1.52 (1.01) 1.40 (0.89) 1.62 (1.08)* 1.69 (1.05) 1.81 (1.09) 1.63 (1.04)
IDAF-4C-P 1.72 (1.07) 1.52 (0.88) 1.87 (1.18)** 1.68 (0.97) 1.66 (0.79) 1.68 (1.05)
† † †
IHLOC 18.50 (4.70) 20.94 (4.20) 17.37 (4.54)*

Values are given as mean (range) or mean (SD). IDAF-4C-B, IDAF-4C behavioural component; IDAF-4C-C, IDAF-4C cognitive compo-
nent; IDAF-4C-E, IDAF-4C emotional component; IDAF-4C-P, IDAF-4C physiological component.
*P < 0.05; **P < 0.01.
†
Scale not used in this sample.
 Swedish version of the Index of Dental Anxiety and Fear
changes. The final version was approved by the author of
the original scale (J.M.A.), after ensuring consistency with
the intentions of the original English-language version of
the scale (see Table S1).
Measurements
The IDAF-4C+ (8) includes three modules: the Anxiety
and Fear module; the Phobia module; and the Stimulus
module. The Anxiety and Fear module, also called the
four-components module (IDAF-4C), consists of eight
items covering central aspects of dental anxiety and fear,
from four theoretically based components: emotional (e.g.
‘I feel afraid or fearful when visiting the dentist’); cognitive
(e.g. ‘I think that something really bad would happen to
me if I were to visit the dentist’); behavioural (e.g. ‘I delay
making appointments to go to the dentist’); and physiolog-
ical (e.g. ‘My heart beats faster when I go to the dentist’).
Each component includes two items, with a five-point Lik-
ert-type scale response format, ranging from ‘Disagree’
(score of 1) to ‘Strongly agree’ (score of 5). Full-scale
scores are given as an average score across the eight items
(range: 1–5).
The Phobia module (IDAF-P) consists of five items with
a yes/no response format. Three of the items are con-
structed as diagnostic specifiers for specific phobias
according to the Diagnostic and Statistical Manual of
Mental Disorders Text Revision (DSM-IV-TR) (16),
including the anxiety being disruptive to daily life (Item
2a), pronounced suffering due to the anxiety (Item 2b),
and an awareness of the anxiety as unreasonable (Item
2c). Two of the items are diagnostic differential items,
according to the DSM-IV-TR, for panic disorder (Item
2d) and social phobia (Item 2e). It is proposed that this
module could be analysed to inform on probable diag-
noses of specific phobias in combination with information
on the anxiety level from the IDAF-4C (8). A strict, speci-
fic DSM-IV dental phobia (P-DENTS, in which S stands
for strict) is defined as a marked level of dental anxiety on
the IDAF-4C (mean score >3), affirmative answer on
Items 2a, 2b, and 2c, and no affirmative answer on the dif-
ferential Items 2d and 2e. A less strict dental phobia diag-
nosis (P-DENTR, in which R stands for relaxed) is
calculated without including an affirmative response to
Item 2c (the unreasonable criteria). In this study, the
degree of affirmation on Items 2a–2c was analysed, and
the responses to Items 2d and 2e were analysed separately.
Also, the prevalence of P-DENTS and P-DENTR was cal-
culated.
The Stimulus module (IDAF-S) consists of 10 items,
describing different possible causes of anxiety and worry
at a dental visit, such as needles and injections, painful or
uncomfortable procedures, and gagging. The module uses a
five-point unidimensional scale response format ranging
from ‘Not at all’ (score of 1) to ‘Very much’ (score of 5).
Each item specifies an aspect of dental care that may cause
anxiety and fear.
The SQDA (17) consists of the question, ‘Are you
afraid of going to the dentist?’, with a four-point Likert-
type scale response format, of: ‘Not at all’ (score of 1); ‘A
little’ (score of 2); ‘Quite a lot’ (score of 3); and ‘Very
much’ (score of 4).
The DFS (1, 14) is one of the most frequently used
measures of dental anxiety. It has 20 items covering avoid-
ance behaviour, somatic reactions during dental treatment,
and ratings of the degree of anxiety in relation to specific
455
segments of dental treatment. Factor analysis has indi-
cated three subscales: ‘avoidance and anticipatory anxiety’
(Items 1, 2, 8–13, and 20); ‘reactions to specific stimuli’
(Items 14–18); and ‘physiological responses’ (Items 3–7)
(18). Items are answered on a five-point Likert-type scale
response format, from ‘Not at all’ (score of 1) to ‘Very
much’ (score of 5). The scores are presented as a total sum
score (range 20–100), and the subscales are also analysed
using mean item scores (range 1–5).
The IHLOC scale from the Multidimensional Health
Locus of Control scale (Form A) (15) contains six items
reflecting tendencies for a person to assign control over
their health status to himself/herself (e.g. ‘I am in control
of my health’). The items are answered on a six-point Lik-
ert-type scale response format, ranging from ‘Disagree’
(score of 1) to ‘Strongly agree’ (score of 6), with high
scores indicating a high level of internal control. The
scores are presented as a total sum score (range 6–36).
The DFS, SQDA, and IHLOC were used to explore the
construct validity of the IDAF-4C+.
Statistical analyses
Descriptive statistics were reported and Pearson r correla-
tion coefficients were used to measure associations between
continuous variables. The Student’s t-test and the chi-
square test were used to compare differences between
groups. Cronbach’s alpha and item-total correlations were
calculated to investigate internal consistency reliability.
Exploratory factor analysis (EFA) was performed using
principal axis factoring (PAF), including a rotation analy-
sis with the Promax procedure, to examine the latent
structure of the data from the IDAF-4C scale in the clini-
cal sample. Differences between dependent correlations
were tested using a method presented by LEE & PREACHER
(19). Effect size was estimated with Cohen’s d (20).
Results
Description of study samples
Age, gender, DFS scores (non-clinical group), IDAF-
4C total mean score, and component mean scores for
the clinical and non-clinical study groups are shown in
Table 1. In the clinical group, female participants
reported significantly more dental anxiety (Table 1).
Also, in the clinical sample, based on the SQDA,
63.8% (n = 264) of the participants reported ‘No dental
anxiety’, 15.9% (n = 66) reported ‘A little dental anxi-
ety’, 11.6% (n = 48) reported ‘Quite a lot’, and 8.7%
(n = 36) reported being ‘Very much anxious of going to
the dentist’, with female participants reporting higher
levels of dental anxiety than male participants (‘No
dental anxiety’, 56.1% vs. 73.1%; ‘A little dental anxi-
ety’, 18.5% vs. 12.6%; ‘Quite a lot’, 13.4% vs. 9.3%;
and ‘Very much anxious of going to the dentist’, 11.6%
vs. 4.9%, respectively, P < 0.001). To explore a possi-
ble impact on the dental anxiety ratings, we compared
subgroups of patients expecting different types of treat-
ment. Of the 414 patients, 297 were able to specify the
kind of treatment expected. We compared those expect-
ing an ‘invasive’ procedure (surgery, extraction, drilling,
scaling, etc.; n = 129) with those expecting something
456 Wide Boman et al.

‘non-invasive’ (examinations, follow-ups etc.; n = 168). Table 3

The mean IDAF-4C scores for the ‘invasive’ and ‘non-
invasive’ groups were 1.70 (SD = 0.97) and 1.51
(SD = 0.89), respectively. However, the difference did
not reach statistical significance (P = 0.075), and the
effect size was small (d = 0.20).
Component matrix from exploratory factor analysis of the
Index of Dental Anxiety and Fear (four-components module)
(IDAF-4C), in the clinical sample
Item Factor loading

Reliability of the IDAF anxiety and fear module
(IDAF-4C)
The internal consistency of the IDAF-4C was calcu-
lated from the clinical sample. The inter-correlations
between single items were high, ranging from 0.62
(Items 1 and 4) to 0.85 (Items 5 and 6). The homogene-
ity of the IDAF-4C was further evidenced by a
Cronbach’s alpha coefficient of 0.95, with corrected
item-total correlations ranging from 0.76 to 0.89. The
removal of any of the items would not have improved
the alpha coefficient value. The inter-correlations
between the four components of the anxiety and fear
module were also high and statistically significant
(Table 2).
The scale structure and reliability of the IDAF
anxiety and fear module (IDAF-4C)
The exploratory factor analysis using PAF showed a
clear one-dimensional structure of the IDAF-4C. The
analysis revealed one factor with an eigenvalue of 6.0,
explaining 74.9% of the variance (Table 3). To investi-
gate the theoretical model with four components under-
lying the scale, a second EFA with a forced four-factor
extraction and Promax rotation was made. However,
this further analysis did not indicate a structure with
different factors.
Validity of the IDAF anxiety and fear module
(IDAF-4C)
Clinical sample: The IDAF-4C and the four compo-
nents were strongly correlated with the SQDA
(Table 2), with the strongest correlation with the emo-
tional items (IDAF-4C-E; r = 0.89), and the weakest
Table 2
Correlations between the Index of Dental Anxiety and Fear
(four-components module) (IDAF-4C), its components, and
Single-Question Assessment of Dental Anxiety (SQDA), in the
clinical sample
1 0.851
2 0.853
3 0.882
4 0.800
5 0.915
6 0.879
7 0.783
8 0.785
Extraction method: principal axis factoring; one component
extracted.
correlation with the cognitive items (IDAF-4C-C;
r = 0.71).
Non-clinical sample: The correlations between the
IDAF-4C components and the DFS, DFS dimensions,
and IHLOC are presented in Table 4. The IDAF-4C
was strongly correlated with the DFS total score
(r = 0.86, P < 0.01). The IDAF-4C had very weak cor-
relations with the IHLOC. The difference between the
correlation of the IDAF-4C with the DFS and the cor-
relation of the IDAF-4C with the IHLOC was statisti-
cally significant (P < 0.001). Among the IDAF-4C
components, the emotional and physiological compo-
nents were those most strongly correlated with the
DFS, whilst the behavioural and cognitive components
showed somewhat weaker correlations.
The phobia module (IDAF-P)
Clinical sample: The five items comprising the IDAF-P
are related to phobic tendencies. Regarding the three
items specifically addressing the DSM-IV diagnostic cri-
teria for specific phobias applied to dental anxiety,
among the 261 patients answering the IDAF-P, 10
(3.8%) replied positively on all three items, whilst 187
(71.6%) indicated none of the three criteria. Table 5
Table 4
Correlations between the Index of Dental Anxiety and Fear
(four-components module) (IDAF-4C) and other scales in the
non-clinical sample
IDAF- IDAF- IDAF- IDAF- IDAF-
4C 4C-E 4C-B 4C-P 4C-C

1 2 3 4 5 DFS 0.860** 0.820** 0.633** 0.762** 0.534**

DFS-A 0.862** 0.819** 0.657** 0.755** 0.518**
1. IDAF-4C DFS-P 0.764** 0.710** 0.518** 0.752** 0.463**
2. IDAF-4C-E 0.948 DFS-S 0.785** 0.749** 0.583** 0.668* 0.520**
3. IDAF-4C-B 0.906 0.787 IHLOC 0.019 0.089 0.025 0.011 0.115
4. IDAF-4C-P 0.950 0.908 0.808
5. IDAF-4C-C 0.880 0.780 0.743 0.764 DFS, dental fear survey; DFS-A, DFS avoidance dimension; DFS-
6. SQDA 0.869 0.890 0.735 0.858 0.707 P, DFS physiological reactions dimension; DFS-S, DFS reactions
to stimuli dimension; IDAF-4C-B, IDAF-4C behavioural compo-
All correlations, P < 0.01. IDAF-4C-B, behavioural component; nent; IDAF-4C-C, IDAF-4C cognitive component; IDAF-4C-E,
IDAF-4C-C, cognitive component; IDAF-4C-E, emotional com- IDAF-4C emotional component; IDAF-4C-P, IDAF physiological
ponent; IDAF-4C-P, physiological component. component; IHLOC, internal health locus of control. **P < 0.01.
 Swedish version of the Index of Dental Anxiety and Fear 457

shows the mean IDAF-4C and SQDA scores related to anxiety towards specific stimulus items associated with
the responses to the three dental phobia items. The higher overall dental anxiety, as reflected by the mean
more dental phobia items that were answered affirma- IDAF-4C scores (Table 6). Within the clinical group,
tively, the higher the level of dental anxiety reported high correlation coefficients were observed for the items
both on the IDAF-4C and the SQDA. Affirmative specifying not being in control (Item 3, r = 0.72), pain-
answers on the items on panic disorder and social pho- ful or uncomfortable procedures (Item 1, r = 0.70), not
bia were also highly related to higher dental anxiety knowing what is going to be done (Item 6, r = 0.65),
(Table 5). The differences in the two dental anxiety and unkind dentist (Item 10, r = 0.71). The weakest
measures between affirmative and non-affirmative correlation was observed for the cost of treatment
responders were statistically significant (P < 0.001) for (Item 7, r = 0.23). A similar pattern of results was seen
both items. None of the participants met the criteria in the non-clinical group. However, items relating to
for strict dental phobia (P-DENTS) and three (0.7%) anxiety of nausea, gagging, and the cost of treatment
participants met the criteria for the less strict dental were not significantly related to dental anxiety assessed
phobia diagnosis (P-DENTR). using the IDAF-4C.
To relate the different anxiety aspects specified in the
IDAF-S to the answers to the dental phobia diagnostic
The stimulus module (IDAF-S)
criteria, a comparison was made between the patients
Clinical sample: The 10 stimulus items were found to in the clinical group indicating at least one of these cri-
correlate significantly with dental anxiety, with greater teria (n = 74) and those answering negatively to all
three of the criteria. Significant differences were
Table 5 observed for all IDAF-S items, except for the one
Phobia module of the Index of Dental Anxiety and Fear about the cost of treatment. The highest mean
(IDAF-P) and dental anxiety measures in the clinical sample differences were observed for the items dealing with
painful or uncomfortable procedures (difference in
IDAF-4C SQDA means = 1.42; 95% CI: 1.11–1.73), not being in control
n (%) Mean (SD) Mean (SD) (difference in means = 1.75; 95% CI: 1.75–2.04), not
No. of dental phobia items affirmed IDAF-P
knowing what is going to be done (difference in
3 out of 3 10 (3.8) 3.90 (0.76) 3.80 (0.42) means = 1.44; 95% CI: 1.14–1.74), and having an
2 out of 3 25 (9.6) 3.42 (0.96) 3.56 (0.65) unkind dentist (difference in means = 1.67; 95% CI:
1 out of 3 39 (14.9) 2.68 (1.07) 2.85 (0.90) 1.07–1.67).
0 out of 3 187 (71.6) 1.50 (0.51) 1.57 (0.75)
F = 108.07; F = 91.03;
P < 0.001* P < 0.001*
Affirmed panic anxiety Discussion
Yes 40 (15.3) 3.24 (1.10) 3.18 (0.87)
No 221 (84.7) 1.72 (0.81) 1.83 (0.98) This study reports on the Swedish translation of the
Affirmed social anxiety Index of Dental Anxiety and Fear (IDAF-4C+) and, in
Yes 36 (13.8) 2.99 (1.00) 3.11 (0.79) addition, includes the first use of this version of the
No 225 (86.2) 1.79 (0.92) 1.86 (1.02) scale with a clinical dental sample. The Swedish IDAF-
IDAF-4C, index of dental anxiety and fear (four-components 4C+ was found to have acceptable psychometric prop-
module); SQDA, single-question assessment of dental anxiety. erties with regard to reliability and validity in both the
*Post-hoc analysis. clinical and the non-clinical samples used.

Table 6
Descriptive statistics for the Stimulus module of the Index of Dental Anxiety and Fear (IDAF-S) for clinical
and non-clinical samples

Clinical group Non-clinical group

Corr. with % Corr. with
Item Mean SD % endorsing† IDAF-4C Mean SD endorsing† IDAF-4C

1 2.84 1.31 84.7 0.704** 2.41 1.15 76.5 0.734**

2 1.45 0.95 24.1 0.501** 1.42 0.84 26.0 0.548**
3 2.22 1.32 59.8 0.716** 1.78 0.97 51.0 0.659**
4 1.73 1.14 37.5 0.585** 1.22 0.50 17.6 0.275
5 1.69 1.04 40.6 0.471** 1.34 0.53 30.0 0.403**
6 2.10 1.30 55.9 0.645** 1.88 1.02 52.0 0.778**
7 2.46 1.46 62.1 0.228** 2.22 1.33 56.9 0.257
8 2.34 1.36 63.2 0.525** 2.18 1.16 66.7 0.612**
9 2.13 1.38 51.7 0.508** 1.37 0.75 23.5 0.273
10 1.82 1.26 37.2 0.713** 1.61 1.02 33.5 0.621**

Corr., Correlation.
†
Proportion of participants with a score indicating dental anxiety (≥2). **P < 0.01.
458 Wide Boman et al.
Dental anxiety was estimated shortly before a dental
appointment, in order to provide relevant information
to the treatment team. This is, we believe, a clinically
interesting use of dental anxiety assessment, and we
therefore believe that the data obtained, using this
mode of assessment, are appropriate for a psychometric
evaluation of the methods used. STABHOLZ & PERETZ
(21) reported a relationship between treatments
expected and dental anxiety reported before treatment.
In our study, the group expecting invasive procedures
scored higher on dental anxiety (mean IDAF-4C
score = 1.70) than the other patients (mean IDAF-4C
score = 1.51). This difference was almost statistically
significant (P = 0.075) and indicates a caveat in treating
patients using invasive procedures.
The scale structure of the IDAF-4C was clearly one-
dimensional, a result similar to that found in previous
studies (8, 11). This is interesting with regard to the
argument for the item selection, which is based on psy-
chological theory in which the anxiety and fear response
is considered to include four components: emotional;
cognitive; behavioural; and physiological. This theoreti-
cally based model is not reflected as sub-dimensions in
this dental anxiety scale using EFA. However, the use
of only two items per component may be one reason
why a one-dimensional factor structure was found.
Another reason may be that a considerable number of
respondents scored a value of 1 (‘Disagree’) on all items
in the IDAF-4C, which may exaggerate the one-dimen-
sionality in the EFA. Perhaps a sample of respondents
with higher levels of dental anxiety would show a
dimensionality in accordance with the theoretically sug-
gested four components.
The correlations between IDAF-4C and other mea-
sures of dental anxiety were moderate to strong, whereas
the correlation with another psychological construct, the
IHLOC was significantly weaker and non-significant.
This was consistent with our hypothesis and thereby
supports the validity of the scale. In the literature, the
IHLOC is not reported to be a strong predictor of den-
tal anxiety, although a significant relationship between
the IHLOC and dental anxiety has been reported in one
study (22). Again, convergent and divergent validity has
been demonstrated previously in non-clinical samples (8,
11). Furthermore, this is the first time that the scale has
been investigated in relation to the DFS.
A closer inspection of the parts of the IDAF-4C
revealed that the emotional component was the compo-
nent that was most strongly correlated with the other
established measures of dental anxiety (DFS and
SQDA). ARMFIELD (8) reported a similar finding,
although in the present study, the correlation was even
stronger. The cognitive component had the weakest cor-
relation with the other dental anxiety measures, a finding
also reported by ARMFIELD (8). As the cognitive compo-
nent is not normally represented in the traditional dental
anxiety scales, this is perhaps not surprising and sup-
ports the argument by ARMFIELD (8), to include the cog-
nitive component in this new scale. The importance of
cognitive factors for the aetiology and maintenance of
dental anxiety has been emphasized previously (23, 24).
Whether the addition of items covering cognitive aspects
also improves the ability of the scale to give information
on other important variables (such as predictive validity,
outcome on treatment, and quality of life) remains to be
investigated. The scale also needs to be tested on dental
phobic patients, who may respond in a different pattern
from non-phobic people.
The analysis of the Phobia module showed a gradi-
ent relationship, in accordance with the hypothesis
that those individuals with responses more strongly
indicating dental phobia also reported the highest
levels of dental anxiety. There was also a clear con-
nection between the level of dental anxiety and indi-
cations of the other phobic anxieties investigated,
such as social phobia and panic disorder. Previous
studies have also found support for the phobia mod-
ule (8, 11). However, to investigate the validity of
the phobia module properly, the module should be
used in a study including clinical measures of diag-
noses of phobic disorders, using structured clinical
interviews.
The IDAF-4C+, with its three modules, is designed
to facilitate flexible use of the scale, whether the pur-
pose is for epidemiological studies, clinical studies, or
clinical practice. The stimulus module is constructed as
a list of information points for the clinician, describing
in greater detail those aspects of dentistry that a speci-
fic patient fears. A similar list of items on anxiety-pro-
voking stimuli is included in other dental anxiety
scales, such as the DFS and the Dental Anxiety Index
(DAI) (9). However, unlike these other scales, emo-
tional responses to stimulus items are not included in
the calculation of an overall anxiety score. It is interest-
ing that the present study, using two different samples,
found almost identical results regarding the most feared
stimulus. This finding adds to our knowledge about the
nature of dental anxiety.
One weakness of the study was the limited size of the
non-clinical sample, with considerably more women,
and with age differences between genders. The lack of
differences in IDAF-4C, reported between genders, is
therefore unreliable.
One of the strengths of this study was that conver-
gent validity evidence was demonstrated using two den-
tal anxiety scales, including the widely used DFS (14).
However, the study would have been improved if other
established dental anxiety measures and variables
related to dental anxiety (attendance, experiences of
dental care, and oral health), as well as other psycho-
logical scales, had been included for the purpose of
validity testing. Also, a larger and more representative
non-clinical sample would be needed to generate nor-
mative values for the wider Swedish population. Addi-
tional and more thorough testing of the IDAF-4C+
remains warranted.
To conclude, the present study presents a Swedish
translation of the IDAF-4C+, showing promising
results for reliability and validity. The study also pro-
poses some areas for additional psychometric examina-
tions of the scale, which has the potential to improve
the methodology of studies on dental anxiety.
 Swedish version of the Index of Dental Anxiety and Fear
Acknowledgements – Carl-Otto Brahm, DDS, for supplying data
for the clinical sample.
Conflicts of interest – The authors declare no conflicts of interest.
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Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Table S1 The Index of Dental Anxiety and Fear (IDAF-4C+).