Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2010; 55: 368–377
ADRF RESEARCH REPORT
doi: 10.1111/j.1834-7819.2010.01256.x

The extent and nature of dental fear and phobia in Australia

JM Armfield* 
*Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia, Australia.
 Department of Dental Public Health Sciences, School of Dentistry, The University of Washington, USA.

ABSTRACT
Background: For the general dental practitioner, fearful patients are harder and more stressful to treat and are most likely
to attend irregularly. This study presents updated and refined dental fear and phobia prevalence estimates in Australia as
well as information on the nature of dental fear and phobia.
Methods: A total of 1084 Australian adults (response rate = 71.7%) completed a mailed questionnaire. The survey
contained four measures of dental fear and phobia, as well as questions regarding potentially anxiety-eliciting dental stimuli
and past aversive dental experiences.
Results: The prevalence of high dental fear ranged from 7.8% to 18.8%, and more incapacitating dental phobia from 0.9%
to 5.4%, depending upon the scale, cut-point and specific criteria used. Dental phobia was significantly associated with
blood-injection-injury (BII) concerns. The cost of dental treatment was endorsed as the most anxiety-eliciting dental
situation (64.5%), followed by fear of needles ⁄ injections (46.0%) and painful or uncomfortable procedures (42.9%).
Anxiety-eliciting stimuli and the type of aversive dental experiences varied significantly by gender, age, income, education,
language spoken at home and dental visiting frequency.
Conclusions: High dental fear and dental phobia are common in Australia although prevalence estimates are highly
dependent on both the scale and cut-points used.
Keywords: Dental fear, phobia, experiences, cost, blood-injection-injury.
Abbreviations and acronyms: BII = blood-injection-injury; CATI = computer-assisted telephone interview; DAS = Dental Anxiety Scale;
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders; IDAF-4C+ = Index of Dental Anxiety and Fear; IDAF-4C = dental
anxiety and fear; IDAF-P = dental phobia; IDAF-S = anxiety-eliciting dental stimuli; NDTIS = National Dental Telephone Interview
Survey; P-DENT = phobia with dental component; SIDAF = single-item dental anxiety and fear.
(Accepted for publication 28 March 2010.)

another study using a single-item measure of dental fear

INTRODUCTION
There is strong and consistent evidence that dental fear
is related to poorer oral health,1–3 reduced dental
visiting4,5 and poorer oral health-related quality of
life.6,7 Fears are important to dental practitioners
because of delayed or cancelled dental appointments
and because treatment can be stressful and difficult to
accomplish.
A small number of studies have investigated dental
anxiety and fear in Australia. An early review paper
estimated a prevalence of dental phobia of 10–14%
based on several disparate sources from both within
Australia as well as elsewhere.8 In the mid 1990s, a
study using the validated Dental Anxiety Scale (DAS)9
found a similar prevalence of high dental anxiety of
14.8%.10 More recently, the prevalence of high dental
fear in Australia was found to be 16.1%,11 while
368
found that 21% of Australian adults were moderately
to extremely afraid of going to the dentist.1
Over time, the reported prevalence of dental fear in
Australia seems to have been increasing. However,
these changes over time may simply reflect the results
of studies employing differing methodologies. For
example, it has been argued that the use of different
dental fear scales may result in different population
estimates of the prevalence of dental fear.12,13 These
variations can also be compounded by the use of
different cut-off scores to define prevalence using a
given scale. While particular cut-off scores might be
supported to some extent by results from phobic
populations or from information on the consequences
of dental fear, they are essentially arbitrary and
changing the value of any cut-off will therefore alter
the prevalence estimate.
ª 2010 Australian Dental Association

Cut-points on dental fear scales are sometimes also
used to estimate the prevalence of dental phobia in
the population. However, phobias differ qualitatively
as well as quantitatively from standard fears. Explicit
criteria for their diagnosis have been established, the
most widely used being those defined by the Diagnostic
and Statistical Manual of Mental Disorders (DSM-
IV).14 Based on these criteria, dental phobia as a type of
specific phobia must represent a marked and persistent
fear that either interferes significantly with a person’s
normal functioning or relationships, or that a person
suffers marked distress about having, which is avoided
or else endured with intense anxiety or distress, which
is recognized as being excessive or unreasonable and
which is not better accounted for by some other mental
disorder. While the need for an admission of excessive-
ness has come under some criticism due to the fact that
many dental fears may have their origin in actual
traumatic experiences,15 the remainder of the criteria
are widely accepted as necessary for diagnosing dental
phobia.
Several studies have explored associations between
dental fear and various demographic, socio-economic
and visit characteristics.3,4,11 However, important
aspects of dental fear, such as what parts of going to
the dentist are of most concern to fearful individuals
and what possible aversive or traumatic experiences
fearful individuals might have encountered, have not
been explored in Australia.
This study presents updated and refined prevalence
estimates of dental fear in Australia. It examines the
nature of dental fears and past aversive experiences and
how these differ across different population subgroups.
Due to the limitations of using any single dental fear,
this study used three different measures. In addition,
an estimate of the prevalence of dental phobia was
attempted using specific diagnostic criteria as put
forward in the DSM-IV clinical psychiatric manual.14
Finally, the paper aimed to examine the nature of dental
fears and past aversive experiences and how these might
differ across different population subgroups.
METHODS
Sampling and participants
The study was nested within the larger 2008 National
Dental Telephone Interview Survey (NDTIS), a com-
puter-assisted telephone interview (CATI) study of a
representative sample of the Australian population. The
Australian Research Centre for Population Oral Health
has conducted six rounds of the NDTIS since 1994
and achieves a 70% response rate using established
methodologies.16,17 Interviewees in NDTIS 2008 were
asked approximately 80 questions regarding the use of
dental services, self-reported oral health and socio-
ª 2010 Australian Dental Association
Dental fear and phobia in Australia
demographic details including income and eligibility for
public dental care. Most of this information is not
reported upon here.
On the completion of their telephone interview,
interviewees aged 18+ years were asked if they would
be interested in participating in a further, unspecified
study. Only those who provided verbal consent were
posted a questionnaire. Adults who agreed to partici-
pate in the further study did so entirely of their own
volition and were under no compulsion or pressure to
subsequently participate in or complete the additional
study. The ‘National Dental Anxiety and Fear Survey’
was sent to a random 25% of available adults
completing the NDTIS. The questionnaire package
contained an information letter, a questionnaire with
questions on dental fear and perceptions of going to the
dentist, and a reply-paid envelope. The questionnaire
was four pages in length, written in English, and
pretesting indicated it took approximately 5–8 minutes
to complete.
MATERIALS
The Index of Dental Anxiety and Fear (IDAF-4C+)
contains three modules dealing with dental anxiety and
fear (IDAF-4C), dental phobia (IDAF-P) and anxiety-
eliciting dental stimuli (IDAF-S).18 The core fear
module contains eight questions, with two items each
relating to the cognitive, physiological, emotional and
behavioural components of dental fear. Possible item
responses range from ‘Disagree’ (1) to ‘Strongly agree’
(5) and the mean was used to obtain a total score on
the IDAF-4C.
The IDAF-P has three items related to diagnostic
criteria for specific phobia as described in the American
Psychiatric Association’s DSM-IV,14 in addition to
questions which allow for the differential diagnosis
of panic attack with agoraphobia and social phobia
(symptoms of which may appear to be similar to those
of dental phobia). The three diagnostic criteria concern
dental fear interfering significantly with a person’s life,
distress in relation to having the fear, and the belief that
the fear is excessive or unreasonable. The DSM-IV
criterion of a ‘marked fear’ was taken from IDAF-4C
scores. However, because the clinical criterion of
‘marked fear’ for specific phobia is imprecise, preva-
lence estimates were calculated using five possible
IDAF-4C scores: ‡2.50, ‡2.75, ‡3.00, ‡3.25 and
‡3.50. The diagnostic criteria employed in determining
three possible dental phobia categories are shown in
Table 1. The three diagnoses were phobia with a dental
component (P-DENT), dental phobia using strict DSM-
IV criteria where the person regards their fear as being
excessive or unreasonable (P-DSMS) and dental phobia
using DSM-IV criteria not requiring an admission of
excessiveness or unreasonableness (P-DSMR).
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JM Armfield
Table 1. Criteria used to define prevalence of different dental phobia diagnoses
Diagnostic criteria
Marked fear as determined by score on IDAF-4C
‘‘My avoidance or fear of going to the dentist significantly
interferes with my life in some way (normal routine,
occupational or academic functioning, social activities, or
relationships)’’ AND ⁄ OR ‘‘I am greatly distressed about my
level of dental fear’’
‘‘I consider my level of dental fear to be excessive or unreasonable’’
‘‘I am afraid of going to the dentist because I am concerned I may
have a panic attack (abrupt fear with sweating, pounding
heart, fear of dying or losing control, chest pain etc.)’’
AND ⁄ OR ‘‘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’’
P-DENT = phobia with a dental component; P-DSMR = dental phobia using relaxed DSM-IV criteria; P-DSMS = dental phobia using strict DSM-IV
criteria.
The IDAF-S contains 10 items, with possible
responses ranging from ‘not at all’ (1) to ‘very much’
(5). Items related to several of the most common
concerns about going to the dentist.18 All items are
analysed individually and therefore scale scores are not
used for the IDAF-S.
The questionnaire also contained the DAS, which
presents four questions related to concerns about
visiting the dentist.9 A score of 13 or greater on the
DAS is widely taken to indicate high dental anxiety.
The DAS is a well-used measure of dental fear with
reported reliability and validity information and has
been used previously in Australia to determine the
prevalence of high dental anxiety.10
All participants were asked whether they had had any
of several possible experiences when visiting a dentist:
‘intense or sharp pain’, ‘considerable discomfort’, ‘felt
like gagging’, ‘fainted or felt light-headed’ or a ‘per-
sonal problem with the dentist’. In addition, people
were asked whether they ‘feel at least moderately
afraid, sickened or unwell’ when seeing ‘blood’, ‘inju-
ries’, ‘medical procedures’ or ‘needles ⁄ injections’.
Additional information, including the participant’s
age and gender, was obtained from the NDTIS CATI. A
further single-item dental anxiety and fear (SIDAF)
measure included in the CATI was ‘would you feel
afraid or distressed when going to the dentist?’ with
possible responses being ‘not at all’ (1), ‘a little’ (2),
‘moderately’ (3), ‘very’ (4) or ‘extremely’ (5). This item
has been used previously in the NDTIS and has been
found to be moderately correlated with both the IDAF-
4C and DAS.18
People were also asked to indicate their total
household income in one of 12 possible categories
which, for the purpose of this study, were collapsed
into four groupings: <$30 000, $30 000–$60 000,
$60 001–$90 000 and >$90 000. Possible categories
for highest level of educational attainment were Year
10, Year 12, certificate ⁄ diploma (graduate diploma and
graduate certificate level, advanced diploma and
370
P-DENT P-DSMR P-DSMS
Yes Yes Yes
Yes Yes Yes
Yes or No Yes or No Yes
Yes or No No No
diploma level, certificate level), undergraduate (bache-
lor degree level) and postgraduate. Finally, information
was obtained on whether the person spoke a language
other than English (LOTE) at home, and how often on
average they would seek care from a dental profes-
sional, with possible responses being ‘two or more
times a year’, ‘once a year’, ‘once in two years’ and ‘less
often than that’.
Statistical analyses
Weighting of the data was used to account for differing
sampling probabilities due to the sampling design and
to adjust the age and gender characteristics for each
sampling stratum across all states and territories to
2008 population estimates made available by the
Australia Bureau of Statistics Census.
The distribution of response scores were provided for
all three dental fear measures, as well as prevalence
estimates for the three possible dental phobia diagno-
ses. Scores and response frequencies for the anxiety-
eliciting dental stimuli and aversive dental experiences
were analysed by selected demographic, socio-
economic and visiting characteristics with statistical
significance assessed using Univariate Analysis of
Variance and F tests. SPSS Version 17 (Chicago, Ill,
USA) was used for statistical analyses and all results
reported use weighted data unless stated otherwise.
Ethics
Ethics approval for the NDTIS 2008 was obtained from
the Australian Institute of Health and Welfare while
ethical clearance was obtained for the nested question-
naire-based dental fear study from the University of
Adelaide Human Research and Ethics Committee. No
financial or other incentive was provided for participa-
tion in the study and participants were informed that
the information provided would be confidential and
the results anonymous.
ª 2010 Australian Dental Association

RESULTS
Response to the survey
A random sample of 1511 Australian adults were
approached to participate in the NDAFS and there were
1084 respondents to the questionnaire (response
rate = 71.7%). Weighting the data reduced the mean
age of the sample from 54.1 years (SD = 17.6) to
44.7 years (SD = 18.3) and the percentage of the
sample that were female from 58.9% to 51.3%. The
age and gender characteristics of the weighted sample,
as well as the distribution of participants from Austra-
lia’s states and territories, did not significantly differ
from the distribution in the Australian population.
Dental fear prevalence
The distribution of scores for each of the three DFA
scales is shown in Figs 1 and 2. In all, 14.6% (95%
CI = 11.8–17.9) of the weighted sample scored at or
above the mid-point of 3 on the IDAF-4C, while 20.6%
Fig 1. Distribution of dental anxiety and fear scores from the IDAF-4C.
Fig 2. Distribution of dental anxiety (DA) scores from the DAS and single-item dental anxiety and fear (DAF) measure.
ª 2010 Australian Dental Association
Dental fear and phobia in Australia
(95% CI = 17.1–24.5) had a score at or above 2.5
(Fig 1). In comparison, 18.1% (95% CI = 14.7–22.1)
of the same participants scored 13 and above on the
DAS (Fig 2). A score of 19 or more, which is sometimes
used as a proxy for ‘dental phobia’, was attained by
1.6% (95% CI = 0.8–2.8) of the weighted sample.
Finally, 18.8% (95% CI = 15.7–22.2) of people indi-
cated that they were at least ‘moderately afraid or
distressed’ when going to the dentist, on the SIDAF
measure (Fig 2).
Dental phobia prevalence
Table 2 presents dental phobia prevalence estimates for
five possible definitions of ‘marked fear’ using IDAF-4C
scores of ‡2.50, ‡2.75, ‡3.00, ‡3.25 and ‡3.50.
Percentages and 95% confidence intervals are provided
for each of the three possible phobia diagnoses. Using
the midpoint score of 3 on the IDAF-4C, the prevalence
of P-DENT, DSMR and P-DSMS was 4.9%, 2.2% and
0.9%, respectively. Changing the IDAF-4C score used
to define a ‘marked fear’ between 2.5 and the more
371
JM Armfield

Table 2. Prevalence estimates (and 95% CIs) of dental phobia diagnoses by differing criteria for the definition of
‘marked fear’
IDAF-4C cut-point P-DENT P-DSMR P-DSMS

% 95% CI % 95% CI % 95% CI

2.50 5.4 4.0, 7.3 2.6 1.7, 4.0 1.0 0.5, 2.1
2.75 5.0 3.7, 6.8 2.3 1.5, 3.6 0.9 0.4, 2.0
3.00 4.9 3.6, 6.7 2.2 1.4, 3.5 0.9 0.4, 2.0
3.25 4.4 3.2, 6.2 2.0 1.2, 3.3 0.9 0.4, 2.0
3.50 4.0 2.8, 5.7 2.0 1.2, 3.3 0.9 0.4, 2.0

CI = confidence interval; P-DENT = phobia with a dental component; P-DSMR = dental phobia with relaxed DSM-IV criteria; P-DSMS = dental
phobia with strict DSM-IV criteria.

stringent 3.5 reduced phobia prevalence estimates but

did not produce any statistically significant changes.
Analyses were conducted of those people with a
phobia, as determined by the IDAF-P, to see if the
diagnosis (using an IDAF-4C score ‡3) was associated
with having ever felt afraid, sickened or unwell at the
sight of blood, injuries, medical procedures or needles
and injections. Overall, 49.2% of the sample responded
that they experience an aversive response upon expo-
sure to one or more of the BII stimuli. Of the 54 people
with P-DENT, 70.4% felt afraid, sickened or unwell in
relation to at least one of the four BII stimuli (compared
to 47.9% of those with no phobia diagnosis; chi-
square = 10.35, p = 0.001). Comparable percentages
for the 24 people with P-DSMR and the 10 people with
P-DSMS were 83.3% and 90.0%, compared with
48.3% and 48.6% respectively and these differences
were also statistically significant. Of the 49.2% of the
sample who admitted feeling afraid, unwell or sickened
at the sight of blood, injections, injuries or medical
procedures, 13.8% claimed to have previously fainted
or felt light-headed when visiting a dentist compared to
only 3.8% of those who stated that they had never felt
sickened by any of the BII stimuli, chi-square = 33.45,
p < 0.001.
Nature of dental fear
Responses to what people were anxious of when
visiting the dentist are shown in Table 3. Anxiety was
greatest for the cost of dental treatment, with 64.5% of
respondents indicating that they were somewhat,
moderately or very anxious. Painful or uncomfortable
procedures and needles or injections were endorsed as
at least somewhat anxiety-provoking by 42.9% and
46.0% of respondents, respectively. The least endorsed
concerns related to feeling embarrassed or ashamed
and feeling sick, queasy or disgusted, with only
approximately 1 in 10 people indicating being at least
somewhat anxious about these things.
Variation in dental fear and concerns by participant
characteristics
There were differences by gender on all three dental fear
scales. On the IDAF-4C, females (mean = 1.91) scored
significantly higher than males (mean = 1.80),
F = 12.32, p < 0.001. Using a score of 3 or greater on
the IDAF-4C, a prevalence estimate of 17.5% was
obtained for females and 11.4% for males, and this
difference was statistically significant, chi-square = 8.02,

Table 3. Response frequencies and descriptive statistics for possible anxiety-eliciting aspects of going to the dentist
(IDAF-4C+ stimulus module items)
Anxiety Per cent endorsing (row %) Descriptive statistics

Not at all A little Somewhat Moderately Very much Mean SD 95% CI

Painful or uncomfortable procedures 15.0 42.0 17.2 12.9 12.9 2.67 1.25 2.55, 2.78
Feeling embarrassed or ashamed 73.9 16.3 6.5 2.1 1.2 1.40 0.80 1.33, 1.47
Not being in control of what is 54.5 26.1 10.9 4.6 3.9 1.77 1.07 1.67, 1.88
happening
Feeling sick, queasy or disgusted 74.5 14.5 6.0 3.8 1.2 1.43 0.86 1.35, 1.51
Numbness caused by the anaesthetic 54.4 28.7 7.6 6.6 2.7 1.74 1.03 1.65, 1.84
Not knowing what the dentist is going 48.4 31.1 13.1 3.6 3.9 1.84 1.04 1.74, 1.93
to do
The cost of dental treatment 21.0 14.6 16.7 14.2 33.6 3.25 1.55 3.11, 3.39
Needles or injections 24.0 30.0 14.5 13.8 17.7 2.71 1.42 2.58, 2.85
Gagging or choking 50.1 26.0 7.9 7.9 8.0 1.98 1.27 1.86, 2.09
Having an unsympathetic or unkind 54.2 18.8 10.4 6.9 9.8 1.99 1.34 1.87, 2.11
dentist

372 ª 2010 Australian Dental Association

 Dental fear and phobia in Australia

p = 0.005. Using the standard cut-point of 13 on the
DAS, females had a prevalence of 20.6% and males had a
prevalence of 15.6%, chi-square = 4.45, p = 0.035.
Finally, using the SIDAF question, 25.3% of females
were at least moderately afraid or distressed about going
to the dentist, compared to only 11.7% of males.
Table 4 presents results on concerns about going to
the dentist by demographic, socio-economic and dental
visiting characteristics. Females rated themselves as
significantly more anxious than did males for 7 of the
10 different aspects of going to the dentist. There were
also significant differences across age groups for all
potential anxiety-eliciting stimuli other than for numb-
ness caused by the anaesthetic and having an unsym-
pathetic or unkind dentist. Lower yearly household
income was associated with greater anxiety regarding
not being in control, the cost of dental treatment,
gagging or choking and having an unsympathetic or
unkind dentist. Concern about not knowing what the
dentist was going to do was greater for those people
with an income <$30 000 and for those with an income
between $60 000 and $90 000. Education had the
fewest associations with anxiety, being significantly
related only to numbness caused by the anaesthetic and
having an unsympathetic or unkind dentist. People who
speak a LOTE at home indicated significantly greater
anxiety than did those people who spoke English at
home, with the exception of feeling embarrassed or
ashamed, where they indicated significantly less anxi-
ety, and for painful or uncomfortable procedures which
was not statistically significant. Finally, less frequent
dental visiting was significantly associated with 8 of the
10 possible anxiety-eliciting stimuli, with the excep-
tions being numbness caused by the anaesthetic and
gagging or choking.
The reporting of aversive experiences by demo-
graphic, socio-economic and visiting characteristics is
presented in Table 5. Between 44% and 48% of the
weighted sample had experienced either intense ⁄ sharp
pain or considerable discomfort while attending a
dentist. Almost a quarter indicated that on at least
one occasion they had felt like gagging, while fewer
indicated fainting or feeling light-headed (8.8%) or
having had a personal problem with the dentist (3.9%).
While men were more likely to have experienced
intense or sharp pain, women were significantly more
likely to have felt like gagging, to have fainted or felt
light-headed, or to have had a problem with the dentist.
Adults aged 25–39 were most likely to have experi-
enced considerable pain or discomfort, but older adults
aged 65+ years were most likely to have reported
feeling like gagging. Lower household income (<$30K)
was associated with fewer experiences of pain (34.1%)
or discomfort (39.5%), but along with those earning
$60K–$90K, relatively greater experiences of gagging
(30.6%). Compared to individuals with a Year 10
education, more than 1.5 times the percentage of
people having a postgraduate education experienced

Table 4. Anxiety-eliciting aspects of going to the dentist by socio-demographic, socio-economic and dental visiting
characteristics
Characteristic Pain Shame Lack of control Queasy Numb Not knowing Cost Needles Gagging Dentist

Gender *** *** n.s. *** * * n.s. *** *** n.s.

Male 2.48 1.29 1.71 1.33 1.67 1.76 3.19 2.47 1.79 1.93
Female 2.84 1.51 1.83 1.52 1.82 1.90 3.30 2.94 2.16 2.06
Age (years) *** * *** * n.s. * *** *** n.s. n.s.
18–24 2.42 1.30 1.50 1.51 1.67 1.68 2.73 2.54 1.87 2.06
25–39 2.93 1.44 1.83 1.49 1.75 2.00 3.49 3.04 1.93 2.13
40–64 2.72 1.46 1.89 1.41 1.83 1.81 3.36 2.72 2.06 1.96
65+ 2.44 1.33 1.72 1.29 1.61 1.83 3.21 2.44 1.98 1.80
Income (per annum) n.s. n.s. * n.s. n.s. * *** n.s. * **
<$30K 2.59 1.51 1.91 1.41 1.79 1.94 3.60 2.67 2.21 2.17
$30K–<$60K 2.62 1.39 1.79 1.37 1.64 1.79 3.30 2.58 1.84 2.15
$60K–<$90K 2.68 1.43 1.82 1.46 1.73 1.96 3.41 2.71 1.95 1.80
$90K+ 2.69 1.32 1.62 1.44 1.78 1.70 2.98 2.83 1.90 1.89
Level of education n.s. n.s. n.s. n.s. * n.s. n.s. n.s. n.s. *
Year 10 2.70 1.33 1.72 1.49 1.64 1.90 3.14 2.67 1.96 2.15
Year 12 2.60 1.53 1.88 1.51 1.86 1.84 3.32 2.71 2.18 2.11
Certificate ⁄ diploma 2.71 1.38 1.78 1.36 1.75 1.81 3.28 2.72 1.93 1.94
Undergraduate 2.58 1.37 1.66 1.41 1.63 1.78 3.14 2.60 1.87 1.71
Postgraduate 2.82 1.38 1.86 1.41 1.94 1.91 3.44 3.14 1.94 2.28
LOTE n.s. * ** ** ** *** ** *** *** ***
No 2.80 1.26 2.02 1.61 1.98 2.15 3.54 3.22 2.48 2.55
Yes 2.65 1.42 1.74 1.40 1.71 1.79 3.20 2.64 1.90 1.92
Visiting frequency *** ** *** ** n.s. *** *** ** n.s. ***
2+ per year 2.51 1.33 1.56 1.28 1.78 1.65 2.93 2.56 1.96 1.66
1 per year 2.45 1.32 1.68 1.36 1.71 1.69 2.99 2.55 1.88 1.91
1 per 2 years 2.84 1.45 1.98 1.58 1.91 2.11 3.53 2.98 2.20 2.11
<1 per 2 years 2.89 1.53 1.97 1.50 1.70 2.03 3.62 2.88 1.96 2.23

ANOVA: *p < 0.05, **p < 0.01, ***p < 0.001.

ª 2010 Australian Dental Association 373
JM Armfield

Table 5. Frequency of aversive experiences, and intense pain or considerable discomfort experienced by
number of experiences, by socio-demographic, approximately 44–48% of people. Aversive experiences
socio-economic and dental visiting characteristics were also shown to vary significantly by individual-level
characteristics.
Characteristic Intense Great Felt Fainted Problem
or sharp discomfort like or light- with
pain gagging headed dentist
Dental fear prevalence
ALL 44.2 47.8 24.5 8.8 3.9
Gender * n.s. *** ** * This study used three different dental anxiety and fear
Male 48.0 49.0 18.7 6.5 2.7 scales and estimates of prevalence were shown to be
Female 40.6 46.5 30.0 11.0 5.1
Age (years) *** *** * n.s. n.s.
dependent upon both the scales and cut-points used.
18–24 45.4 41.0 23.9 8.3 5.4 With the single-item measure, the prevalence estimate
25–39 49.8 58.8 17.6 8.0 2.7 was either 18.8% or 7.8% depending on whether
40–64 47.3 49.2 27.4 10.8 4.2
65+ 27.9 36.4 28.8 6.0 3.3 the mid-point of the scale (‘moderately afraid or
Income ** * *** n.s. n.s. distressed’) was incorporated into or excluded from the
(per annum) prevalence estimate, respectively. For the DAS, a cut-
<$30K 34.1 39.5 30.6 8.1 3.8
$30K–<$60K 52.2 46.5 15.0 8.7 5.5
point of 13 is generally used to define ‘dental anxiety’ and
$60K–<$90K 41.9 51.6 32.9 9.8 2.0 this study found that 18.1% of the sample had a DAS
$90K+ 47.7 52.8 21.9 7.7 4.5 score of 13 or greater. A score of 3 or greater on the
Level of education n.s. *** n.s. * n.s.
Year 10 41.3 40.8 20.1 7.1 5.4
IDAF-4C was reported by 14.6% of people. The
Year 12 48.5 45.1 28.5 13.2 5.5 variation in prevalence estimates is a function of both
Certificate ⁄ 44.2 50.9 26.1 7.2 2.6 the differences in content covered by the scales and the
diploma
Undergraduate 42.9 44.3 24.0 9.9 2.1
different range of scores used to define prevalence.13
Postgraduate 42.9 64.2 16.9 3.9 6.6 A previous study found an unweighted dental fear
LOTE ** n.s. n.s. n.s. n.s. prevalence of 14.9% and a weighted prevalence of
No 56.3 49.3 22.1 8.1 5.9
Yes 42.4 47.6 24.9 8.8 3.7
13.7% in 1995 using a cut-point of 13 on the DAS in a
Visiting frequency n.s. n.s. *** n.s. n.s. similarly large sample of the Australian population.10
2+ per year 44.6 44.2 34.8 8.0 5.6 Given the prevalence of 18.1% found in this study
1 per year 44.4 48.8 21.1 9.0 4.0
1 per 2 years 43.0 47.7 22.1 9.9 2.9 using the same scale and cut-point, there is some
<1 per 2 years 42.3 47.9 22.3 9.0 3.2 indication that dental anxiety may have increased
somewhat between 1995 and 2008. One possible
ANOVA: *p < 0.05, **p < 0.01, ***p < 0.001.
cohort difference between these two times that may
explain the apparent change is reduced dental disease19
considerable discomfort. However, participants with a which may impact on learning experiences and percep-
postgraduate education were the least likely to report tions of going to the dentist. Another possibility is that
having fainted or having felt light-headed. Finally, the changes are due to the dramatic reductions in
people who spoke a LOTE at home were significantly edentulism in Australia19–21 as edentulous people have
less likely to have experienced sharp or intense pain, been found to have lower dental fear than dentate
and people who visited the dentist 2+ times a year were people.11 Table 6 compares prevalence estimates from
more likely to report having felt like gagging than were 1995, which were from unweighted data, alongside
less frequent dental visitors. both weighted and unweighted prevalence estimates
from the current study by both gender and the age
categories reported in the earlier study. The unweighted
DISCUSSION
age and gender distribution in the current study is
This study presents information regarding the extent reasonably close to that reported by Thomson et al.10
and nature of dental fear and phobia among Australian and the unweighted prevalence estimates, other than for
adults. Dental fear was shown to be common, although 45–64-year-olds, are closer to the findings from 1995
estimates of prevalence were dependent on the dental than are the weighted estimates. Both males and
fear scale used as well as the cut-points adopted on females have slightly higher prevalence estimates but
those scales. Dental phobia prevalence was lower and the biggest differences are seen for adults over the age
found to range from 0.9% to 5.4% depending upon the of 45. It is possible, therefore, that reported declines in
diagnostic criteria used to define phobia. People indi- edentulism for people over the age of 45 are associated
cated that they were mainly anxious about the cost with the increase in the prevalence of high dental fear
of dental treatment, the possible pain, and receiving for these age groups. Given the continuing trend for
needles, and these anxieties varied significantly by people to retain their teeth longer, it will be interesting
several individual-level characteristics. Finally, aversive to observe the associations between population preva-
experiences were shown to be relatively common, with lences of edentulism and dental fear over time.
374 ª 2010 Australian Dental Association

Table 6. Australian comparisons of dental anxiety
prevalence (using a DAS cut-point of 13) by age and
gender
Thomson et al.10 Current study
Prevalence (%) Weighted
prevalence (%)
Age
18–34 15.1 16.7
35–44 19.7 24.4
45–64 12.8 17.4
65+ 9.7 17.9
Gender
Male 9.7 15.6
Female 18.8 20.6
Dental phobia prevalence
Estimates of dental phobia prevalence in this study are
appreciably lower than estimates of high dental fear,
but this is to be expected given the extra criteria
necessary for phobia diagnosis. Using the P-DSMR
criteria, 2.2% of the Australian adult population were
estimated as having a diagnosable dental phobia
disorder and this is similar to the prevalence of several
types of major anxiety disorders found in the Australian
population.19 Certainly, dental phobia represents one
of the most common types of specific phobia. For
example, using somewhat different diagnostic criteria
to those used here, a study in the Netherlands found the
prevalence of dental phobia (3.7%) to be higher than
all 10 other specific phobias (including heights, spiders
and flying) that were investigated.22
One of the subtypes of specific phobia is the BII type,
which is believed to involve distinct physiological
vasovagal reactions including accelerated heart rate
followed by a rapid drop in blood pressure, which may
lead to fainting or light-headedness. Some researchers
have argued that dental phobia can be construed as a
subtype of a BII phobia.23 Consistent with several other
studies,24–26 this study found a relationship between
dental phobia and the BII concerns of blood, injuries,
medical procedures and needles ⁄ injections. However,
other researchers have argued that although dental and
BII fears tend to be highly associated, dental phobia
should not be seen as a type of BII phobia.24,27
Nonetheless, the high association between dental
fear ⁄ phobia and BII concerns indicates that dentists
may need to take these additional elements into account
when treating some fearful individuals.
Specific concerns about going to the dentist
This study found that anxiety regarding the cost of
dental treatment was the single biggest concern about
going to the dentist. Approximately 65% of all people
stated that they were at least somewhat anxious about
ª 2010 Australian Dental Association
Dental fear and phobia in Australia
the cost of dental care. The reality underlying the
considerable anxiety over dental costs is that out-of-
pocket expenditure by individuals comprises two-thirds
of all dental expenditure in Australia.28 In addition,
the costs of dental services in Australia have been rising
Unweighted steeply.29 This is of concern given that Australian
prevalence (%)
research has demonstrated that affordability of dental
services is associated with both oral health outcomes30
15.0 and dental visiting.31 Indeed, approximately 30% of
23.1
18.2 the Australian population avoid or delay dental care
13.7 due to the cost.32 This study supplements existing
research by showing that not only does cost contribute
11.4
20.5 to oral health outcomes and service use, but that it is a
source of considerable anxiety for people visiting the
dentist.
Other than cost, the most common anxieties about
going to the dentist were needles or injections and
painful or uncomfortable procedures. This fits with a
considerable body of literature reporting on these
concerns among dental patients. Interestingly, while
just over one-quarter of people were at least somewhat
anxious about having an unsympathetic or unkind
dentist, less than 4% of people indicated that they had
ever experienced a personal problem with a dentist.
Some researchers have claimed that feeling embarrassed
or ashamed is an important component of dental fear
and avoidance,33 and about 1 in 6 respondents in this
study indicated this aspect of going to the dentist as
being at least somewhat anxiety-eliciting.
Many people in this study also expressed anxieties
related to gagging or choking, having an unkind or
unsympathetic dentist, not being in control, not know-
ing what the dentist is going to do, and feeling
embarrassed or ashamed. Of note is that these anxieties
relate to either the procedures or behaviour of the
dentist and that they are evident despite large reduc-
tions in oral disease in Australia, significant changes in
the dental clinic brought about by new technologies and
treatment advancements, and an increasing emphasis
on patient and dental fear management in Australia’s
dental teaching institutions. While there is no evidence
of dentists having a causal role in these anxieties, it is
nonetheless the case that dentists are well placed to play
a leading role in the management or alleviation of
dental fears and phobias in the future.
Demographic, socio-economic and visiting
characteristics associated with dental fear
An almost ubiquitous finding in the literature is for
females to report greater dental fear than males and this
study confirmed these results using three different DFA
measures. Indeed, females also rated themselves as
more anxious of all 10 items on the IDAF-S than did
males, although three of these differences were not
statistically significant. The biggest differences were
375
JM Armfield
fear of pain, shame or embarrassment, feeling queasy or
disgusted, needles or injections, and gagging or chok-
ing. In terms of aversive experiences, females were less
likely than males to have experienced intense or sharp
pain but more likely to have experienced gagging or
fainting. The reasons for these differences have not
yet been well explained, although possibilities include
differences in pain perception,34 attitudes to pain and
control,35 threat avoidance36 and even genetics.37
This study also found differences in anxiety-eliciting
dental stimuli and aversive experiences across a number
of other individual-level characteristics, including age,
income, education, speaking a language other than
English and dental visiting frequency. The nature of
these associations was often complicated. For example,
people with the highest household income were more
afraid of pain and needles, but least anxious about
feeling embarrassed or ashamed, lacking control or not
knowing what the dentist was going to do. As might be
expected, however, lower income was significantly
associated with concerns regarding the cost of dental
treatment. In terms of associations with age, the
youngest and oldest people tended to report the least
anxieties concerning fear-relevant situations and stim-
uli, and it was adults aged 65+ who had the least
experience of intense pain or considerable discomfort.
Of note is that those people who visited the dentist
less often were not more likely to have had aversive
experiences at the dentist. This is consistent with the
idea that it is not negative experiences per se, but
perceptions of the dentist, which are the most impor-
tant determinants of dental fear and avoidance.38,39
However, those people who visited the dentist less
frequently had significantly greater fear relating to pain,
feeling embarrassed or ashamed, lack of control, feeling
queasy, nauseated or disgusted, not knowing what
the dentist was going to do, needles, having personal
problems with the dentist and the cost of dental
treatment. This represents a substantial list of possible
barriers to overcome in order to increase dental visiting
among those who go to the dentist infrequently.
CONCLUSIONS
Knowledge of the prevalence and extent of dental fear
is important because, when taken in conjunction with
the implications of dental fear on oral health and
service utilization, it highlights the need for action to
alleviate this serious health issue. Despite changes in the
teaching and practice of dentistry, it remains the case
that many Australians have high levels of dental fear
and a small but significant number have what can be
classified as dental phobia. Indeed, there is even some
evidence that dental fear is increasing somewhat in
Australia. Results indicate that the causes of dental fear
may be varied and complex.
376
ACKNOWLEDGEMENTS
This study was funded by a grant from the Australian
Dental Research Foundation.
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Address for correspondence:
Dr Jason Armfield
Department of Dental Public Health Sciences
The University of Washington
1959 Pacific Street
Box 357475
Seattle
Washington 98195
USA
Email: jason.armfield@adelaide.edu.au
377