| |
Received: 10 November 2019    Revised: 16 April 2020    Accepted: 15 May 2020
DOI: 10.1111/hsc.13056
ORIGINAL ARTICLE
The extent and nature of dental anxiety in Australians
experiencing homelessness
Kumiko Yokota BSDc (Hons), Graduate1 | Sheng Wey Yu BSDc (Hons), Graduate1 |
Tara Tan BSDc (Hons), Graduate1 | Jan Anderson Dip Nurs, Nurse Manager2 |
Nicole Stormon BOH, Lecturer1
1
School of Dentistry, Oral Health Centre,
The University of Queensland, Brisbane,
Qld, Australia
2
Queensland Health, Oral Health Services,
Community and Oral Health Directorate,
Royal Brisbane & Women’s Hospital,
Brisbane, Qld, Australia
Correspondence
Nicole Stormon, 288 Herston Road, Herston,
Brisbane, Qld 4006, Australia.
Email n.stormon@uq.edu.au
|
2352     © 2020 John Wiley & Sons Ltd
Abstract
High dental anxiety is a major barrier to accessing dental care and has been found
to be experienced to a greater extent in the homeless population. No studies have
investigated the extent and nature of dental anxiety in Australians experiencing
homelessness and was the aim of this study. Participants were recruited from four
not-for-profit organisations in inner Brisbane using convenience and snowball sam-
pling. The Dental Anxiety Questionnaire (DAQ) and the Index of Dental Anxiety and
Fear (IDAF-4C+) questionnaire and oral health screening were completed by peo-
ple experiencing homelessness in Brisbane, Australia, and compared to population
norms. Descriptive statistics were calculated, and non-overlapping confidence in-
tervals considered significantly different. The majority of the participants (n  =  66)
were male, a current smoker, unemployed and living in government supported hous-
ing. Most of the participants rated their oral health as poor/fair (n = 46, 71.9%) and
their oral function as good or higher (n  =  34, 53.1%). Using the single-item DAQ,
28.2% (n = 19) of people experiencing homelessness had high dental anxiety, com-
pared to 16% of the general Australian population. The mean summed IDAF-4C+ fear
module score was 18.02 (CI 15.60–20.43), which was significantly higher than the
Australian population (µ  =  14.40, CI 13.93–14.86). The highest mean score in the
IDAF-4C+ stimulus module was feeling embarrassed or ashamed as anxiety inducing
(µ = 2.27, CI 1.89–2.64) and was significantly different from the general Australian
population (µ = 1.40, CI 1.33–1.47). The poorer overall self-rated oral health by the
homeless population may induce feelings of embarrassment or shame, highlighting
the differing psychosocial aspect to dental anxiety experienced by this population.
Managing dental anxiety is needed to improve accessing to dental care for this popu-
lation. Multidisciplinary care from social workers, mental health workers and dental
practitioners may be beneficial in managing fear.
KEYWORDS
dental anxiety, dental fear, dental phobia, homeless persons, vulnerable populations
wileyonlinelibrary.com/journal/hsc Health Soc Care Community. 2020;28:2352–2361.
YOKOTA et al.
1 |  I NTRO D U C TI O N
Over 116,000 people were identified in Australia as experiencing
homelessness in 2016 (Australian Bureau of Statistics,  2018). This
population is growing in Australia, with a recorded 4.6% increase
between 2011 and 2016 (Australian Bureau of Statistics,  2018).
However, these statistics do not represent the true extent of
people experiencing homelessness with many unaccounted for,
often referred to as the ‘hidden homeless’ (Australian Bureau of
Statistics, 2018). Those experiencing homelessness are often diffi-
cult to survey due to their transient lifestyle (Australian Bureau of
Statistics, 2018). A person is classified as homeless by the Australian
Bureau of Statistics when they do not have adequate accommoda-
tion or long-term living arrangements, with limited access to space
for social interactions (Australian Bureau of Statistics, 2018).
There is a disparity in oral health between those with lower and
higher incomes, with the former experiencing double the rate of
untreated caries (Slade, Spencer, & Roberts-Thomson,  2004). The
Australian Health Ministers’ Advisory Council identified people who
are socially disadvantaged or with low incomes (which includes peo-
ple experiencing homelessness) as a priority population (Australian
Health Ministers’ Advisory Council,  2015). Other competing prior-
ities, such as obtaining basic necessities such as food and housing,
result in dental health being deprioritised for people experiencing
homelessness (Ford, Cramb, & Farah,  2014; Stormon, Pradhan,
McAuliffe, & Ford, 2018). Substance misuse is common among peo-
ple experiencing homelessness and contributed to poorer mental
health, nutrition, oral health and subsequently poorer quality of life
in this population (Ford et  al.,  2014). Lower health literacy in this
population and social exclusion they experience also contribute to
the many barriers they face in achieving good oral health (Adams
et al., 2009). The most cited barrier to accessing regular dental care
in Australia was financial constraint, with long waiting lists for subsi-
dised care and high out-of-pocket fees for dental services (Council of
Australian Governments, Refor Council 2014; Stormon et al., 2018).
Dental anxiety has also been found as a prominent barrier to dental
attendance, even when treatment does not require financial com-
pensation (Ford et al., 2014; Stormon et al., 2018).
Dental anxiety is defined as an ‘aversive emotional state of ap-
prehension or worry in anticipation of dental procedures’ (Seligman,
Hovey, Chacon, & Ollendick, 2017). The term has been used inter-
changeably with dental fear in the literature. As with other fears and
phobia, dental phobia is also an anxiety disorder but defined as per-
sistent and excessive fear of dental stimuli (Seligman et  al.,  2017).
The nature of dental anxiety can differ between individual and pop-
ulations, with population-level studies finding the cost of treatment,
needles and gagging to be prominent stimuli for triggering anxiety
(J. Armfield, 2010a). In Australia, 7.8%–18.8% of the general popu-
lation were reported to have high dental anxiety and 0.9%–5.4% ex-
periencing dental phobia (J. Armfield, 2010a). Multiple studies have
found high dental anxiety to be associated with delayed visits lead-
ing to poorer oral health and subsequently higher symptom-driven
treatment (Armfield, Stewart, & Spencer, 2007; Schuller, Willumsen,
|
      2353
What is known about this topic?
• Prominent barriers to accessing dental care for people
experiencing homelessness include cost, long waiting
lists for subsidised care, and dental anxiety.
• Dental anxiety has been associated with delayed dental
visiting behaviours and leads to poorer oral health and
symptom-driven treatment.
• Explored extensively in the general Australian popula-
tion, the extent and nature of dental anxiety has not
been investigated in people experiencing homelessness.
What this paper adds?
• Compared to population norms, a higher proportion of
people experiencing homelessness reported dental anx-
iety and phobias.
• The nature of dental anxiety differed to the general
population as more people experiencing homelessness
reported embarrassment or feeling ashamed as anxiety
inducing.
• Understanding dental anxiety in vulnerable populations
can inform multidisciplinary approaches to overcoming
this prominent barrier to accessing dental care.
& Holst, 2003; Thomson, Stewart, Carter, & Spencer, 1996). As a re-
sult, the treatment required is often more invasive, increasing dental
anxiety and resulting in a ‘cycle of dental fear’ (Armfield et al., 2007).
Compared to the general population in Belfast and Scotland, dou-
ble the proportion of people experiencing homelessness had dental
anxiety and experienced it to a greater severity (Beaton, Coles, &
Freeman, 2018; Collins & Freeman, 2007). However, no such stud-
ies measuring the extent and nature of dental anxiety in this pop-
ulation have been undertaken in Australia. These previous studies
have also used fear scales that were criticised to have poor con-
struct validity, not measuring the physiological, behavioural and
cognitive components of fear and measuring fear stimuli itself (J. M.
Armfield, 2010b). The Index of Dental Anxiety and Fear (IDAF-4C+)
module questionnaire has been developed to address these flaws,
and the single-item Dental Anxiety Questionnaire (DAQ) is another
single-item questionnaire that has been used in epidemiological re-
search with good validity (J. M. Armfield, 2010b; Neverlien, 1990).
The single-item DAQ is a useful tool for identifying the prevalence
of dental anxiety, whereas the IDAF-4C+ is useful for exploring the
nature and severity of various dental anxiety inducing stimulus.
Previous Australian research has demonstrated that those with a low
socioeconomic status were more likely to report high dental anx-
iety measured with the IDAF-4C+ or the DAQ (Armfield, Spencer,
& Stewart,  2006). A significantly larger proportion of women and
those aged 40–64 years old were found to experience high dental
anxiety (Armfield, 2011). A study undertaken in Scotland using the
Modified Dental Anxiety Scale (MDAS) also found a higher extent of
 |
2354       YOKOTA et al.
high dental fear in women within the homeless population (Beaton
et al., 2018).
Understanding the extent and nature of dental anxiety in this
population can help dental practitioners deliver appropriate care
and inform broader health service policies to enhance the targeted
pathways for improved access to dental care. The aim of this study
was to explore dental anxiety in Australian people experiencing
homelessness by using previously validated and reliable measures
of dental anxiety. The IDAF-4C+ and DAQ will be used in this study
to measure levels of dental anxiety within the homeless population.
Australian population norms for the IDAF-4C+ and DAQ have been
established in previous studies and can be used as a comparison to
determine the extent and nature of dental anxiety in this population
(J. Armfield, 2010a, 2011; Armfield et al., 2006).
2 |  M E TH O DS
2.1 | Study sample
Due to the transient nature of those experiencing homelessness, this
study used non-probability convenience sampling to recruit partici-
pants. All participants were ≥18 years old and living in Australia. Data
were collected through a program providing expedited referrals and
access to dental services for people experiencing homelessness at
four non-profit community organisations in October 2018. The com-
munity organisations ranged from 1 to 4 km away from Brisbane's
Central Business District. These organisations provide several social
services including food, accommodation, employment services and
more. Participating community organisations client bases ranged
between 2 and 10,000 clients annually, with <100 individuals using
services on a daily basis.
In the dental referral program, a dental practitioner and volun-
teer dental students visited the community organisations to provide
interested clients an oral health screening, preventive oral health in-
formation, oral hygiene products and an immediate referral to public
oral health services for free dental care. The dental referral program
was being evaluated through voluntary participation in question-
naires. The community organisations advertised the dental referral
program and research project to their clients. Those who took part
were aware of this initiative through word of mouth and participa-
tion in this study was voluntary. Two of the locations were visited
twice, to generate a snowball effect to increase the sample size.
2.2 | Ethical approval
This study was reviewed and approved by the Royal Brisbane &
Women's Hospital Human Research Ethics Committee (project no.
HREC/17/QRBW/475) and the University of Queensland Human
Research Ethics Committee (project no. 2,017,001,407). All par-
ticipants provided informed consent to participate in the research.
Due to the vulnerable nature of this population, researchers in
collaboration with the community organisation staff provided assis-
tance to the clients by reading the consent forms where necessary
and explaining in lay terms involvement in the dental referral pro-
gram and research. Participants were provided the option to receive
a referral to dental services without participating in the research,
and one client in the program opted for this. Participants were not
excluded if they identified as having a substance use disorder or
mental illness and were offered support through their community
organisation. Participants were allowed to cease participation at
any time and questionnaires independently or with assistance from
researchers.
2.3 | Outcome measures
Researchers assisted the participants to complete the survey via
electronic devices prior to dental screening. The survey consisted
of three parts: demographics, dental history and dental anxiety/
fear scales. Demographic questions included participant age, gen-
der, Aboriginal and Torres Strait Islander status, country of birth,
highest level of education, current smoking status, if the participant
had private insurance for dental expenses, employment status and
current residential status. Participants were asked to rate their oral
health and function (poor to excellent), tooth or denture cleaning
frequency, reasons for dental visits and time since last dental visit.
To assess dental anxiety, participants completed two question-
naires: the single-item DAQ and IDAF-4C+. The DAQ has previously
been demonstrated to have good validity and reliability, consisting
of only one item (Neverlien, 1990). Participants were asked ‘are you
afraid of going to the dentist?’, with four response options: ‘not at all’,
‘a little’, ‘yes, quite’ and ‘yes, very’.
The IDAF-4C+ is also reliable as demonstrated by its good in-
ternal consistency (Cronbach's α  =  0.94) and high validity (J. M.
Armfield, 2010b). The IDAF-4C+ contains three modules, also known
as IDAF-4C or the core fear module (8 items), the phobia module
(5 items) and stimulus module (10 items), totalling 23 items. The core
module measured levels of dental anxiety level and contained eight
statements, for which the responses were measured on a 5-point
scale ranging from ‘disagree’ to ‘strongly agree’. The second mod-
ule on phobia contained five items, in which the responses were
‘yes’ or ‘no’. The stimulus module 3 measured the extent to which
participants were anxious towards 10 potentially anxiety-inducing
stimuli: pain, embarrassment, lack of control, numbness, feeling sick,
treatment costs, needles, gagging, not knowing what was happening
and having an unsympathetic dentist. The response to each stimuli
was measured on a 5-point scale ranging from ‘disagree’ to ‘strongly
agree’.
2.4 | Oral health assessment
Dental screenings were undertaken on participants in a private
room at the community organisations. A disposable MirrorLite
YOKOTA et al. |
      2355

was used for dental screenings by a qualified and trained dental TA B L E 1   Demographics of the study sample (n = 64) compared
professional undertook the screenings and was assisted by three to the general Australian population

trained and calibrated dental students. Oral hygiene and gingi- Australian
val health were assessed using the Periodontal Disease Index Homeless population populationa 
(Ramfjord,  1967). The screening was performed without a peri-
n % (95% CI) %
odontal probe and the index was modified for visual examination
Age (years)
only, to reduce discomfort and risk to medically compromised pa-
15–44 27 42.2 (30.7–54.4) 53.6
tients. Plaque, calculus and gingivitis severity were assessed by
sextant and a score between 0 and 3 was recorded. The scale of 45+ 37 57.8 (45.6–69.3) 46.4

the scores ranged from 0, indicating none observed, to 3, indicat- Gender

ing abundance of plaque and calculus or marked gingival inflam- Male 39 60.9 (48.7–72.2) 53.6
mation and spontaneous bleeding (Ramfjord, 1967). A score ≥2 in Female 25 39.1 (27.8–51.3) 51.3
any sextant were classified as unhealthy. The number of visible Indigenous status
decayed, missing and filled teeth was counted, as a full dental ex- Yes 8 12.5 (6.1–22.2) 1.9
amination with radiographs was not able to be undertaken in a Country of birth
community setting.
Australia 46 71.9 (60.1–81.7) 32.5
Highest level of education
Primary school or 9 14.1 (7.2–24.1) 4.3
2.5 | Statistical analysis less
Smoking
Descriptive analysis of the demographic, oral hygiene, oral
Current daily smoker 38 59.4 (47.1–70.8) 14.5
health, DAQ and IDAF-4C+ data was performed using IMB SPSS
Employment
Version 25. Frequency, proportion and 95% confidence interval
Unemployed 59 92.2 (83.7–97.0) 4.7
of the proportion for the demographic, oral hygiene and oral
Residence
health data were calculated and compared to Australian popula-
tion data were possible (Australian Bureau of Statistics,  2016; Alone 14 21.9 (13.1–33.1) –

Brennan, Luzzi, Ellershaw, & Peres, 2019). Frequencies and pro- With a friend or 15 23.4 (14.4–34.8) –
family member
portions were also calculated for the DAQ and compared to
data reported for the general Australian population (Armfield Government 24 37.5 (26.4–49.7) –
supported/
et  al.,  2006). Participants were classified as having high dental
community housing
anxiety from the single-item DAQ if they answered ‘yes, quite’
On the streets 10 15.6 (8.3–25.9) –
and ‘yes, very’. or emergency
IDAF-4C+ items were calculated by module and compared to accommodation
Australian norm data (J. Armfield,  2010a, 2011). Non-overlapping Other 1 1.6 (0.2–7.1) –
confidence intervals were considered significantly different. All items a
2016 ABS: Brisbane, 15+ years, n = 1,826,406 (Australian Bureau of
in the fear module were summed, and the mean and 95% confidence Statistics, 2016). 95% confidence intervals (CIs) not reported.
interval were calculated for the sample. For each item in the stim-
ulus module, the mean score and 95% confidence intervals were
calculated. 3 | R E S U LT S
The IDAF-4C+ phobia module items were used to determine
phobia diagnostic criteria which included: phobia with a dental 3.1 | Demographics
R
component (P-DENT), dental phobia using the relaxed (P-DSM )
and strict (P-DSMS) Diagnostic and Statistical Manual of Mental Sixty-six clients of the community organisations participated in the oral
Disorders 4th ed (DSM-IV) criteria (Table  S1; Segal,  2010). The health screening and surveys. The majority of the participants were
prevalence of phobia was calculated by the proportion and 46 years old or older, male, not of Aboriginal or Torres Strait Islander back-
95% confidence intervals of participants which met the diag- ground, born in Australia, completed secondary school, a current smoker,
nostic criteria (Table  S1) and a minimum total IDAF-4C+ mean unemployed and living in government supported housing (Table 1).
score of 3.
A chi-squared test for independence was performed to assess
the relationships between dental anxiety (high or low dental anx- 3.2 | Oral health and hygiene
iety as determined by DAQ) and the demographic and oral health
measures. p-values lower than 0.05 were considered statistically Self-reported oral health and oral hygiene behaviours of the partici-
significant. pants are reported in Table  2. Most of the participants rated their
2356      | YOKOTA et al.

TA B L E 2   Self-reported and assessed

Homeless population
n % (95% CI)
Australian
oral health of people experiencing
populationa 
homelessness (n = 64) compared to the
% (95% CI) general Australia population

Self-reported oral health

Self-reported oral health: poor/fair 46 71.9 (60.1–81.7) 23.9 (22.8–25.0)a,b 
Self-reported oral function: poor/fair 30 46.9 (35.0–59.0) –
Usual reason for visiting a dental 18 28.1 (18.3–39.9) 64.9 (63.5–66.2)a,b 
professional: check-up
Last visit to a dental professional: in 24 37.5 (26.4–49.7) 57.5 (56.1–59.0)a,b 
the last 12 months
Cleaning teeth/dentures frequency
When I remember 2 3.1 (0.7–9.6) –
Less than once a day 15 23.4 (14.4–34.8) –
Once a day 23 35.9 (25.0–48.1) –
Twice a day or more 24 37.5 (26.4–49.7) –
Oral health screening
Plaque health (n = 62)
Healthy 40 64.5 (52.2–75.5) –
Calculus health (n = 62)
Healthy 40 64.5 (52.2–75.5) –
Gingiva health (n = 62)
Healthy 45 72.6 (60.6–82.5) –
c
Decayed, missing, filled teeth score  
Decayed 64 4.3 (3.1–5.4) 0.6 (0.5–0.7)b 
Missing 64 5.2 (3.7–6.7) 4.6 (4.3–4.8)
Filled 64 5.3 (4.2–6.5) 7.7 (7.4–8.0)b ,c
a
2017–18 NSAOH: Australia 15+ years, n = 15,731 (Brennan et al., 2019).
b
Significant difference due to non-overlapping confidence intervals (CIs).
c
Reports mean and 95% CI of the mean in parenthesis.

F I G U R E 1   Response to Dental
Anxiety Questionnaire survey by the
general (n = 7,312) and homeless (n = 64)
Australian population. Population data:
Armfield et al. (2006)

oral health as poor/fair (71.9%) and their oral function as good or when they have problem (68.8%). Most participants reported last
higher (53.1%). The majority brushed their teeth at least once a day visiting a dental professional over 12  months ago or could not re-
(73.4%) and their usual reason for visiting a dental professional was member when they last saw one (62.6%).
YOKOTA et al. |
      2357

3.3 | Dental anxiety The highest mean score for the stimulus module was the cost
of dental treatment for both this sample and the Australian popula-
Using the single-item DAQ 28.2% (n  =  19) of people experiencing tion norm. The mean score of ‘feeling embarrassed or ashamed’ was
homelessness had high anxiety, compared to 16% of the general significantly higher in the homeless population (2.27, CI 1.89–2.64),
Australian population (Figure 1). Table 3 reports the mean summed than the Australian population. In contrast, this was the least anxiety
IDAF-4C module scores for the participants in this study compared eliciting for the general Australian population with a mean score of
to Australian population norms. The mean summed score of the den- 1.40 (CI 1.33–1.47, n = 1,084).
tal anxiety and fear module was 18.02 (CI 15.60–20.43), which was Dental phobia prevalence calculated by the IDAF-4C+ diagnos-
significantly higher than the Australian population (14.40, CI 13.93– tic criteria's is reported in Table  3. The prevalence of participants
14.86, n = 1,063). with a diagnostic classification of P-DENT, P-DSMR and P-DSMS was
23.9% (CI 13.8–34.6), 13.1% (CI 6.4–23.2) and 6.6% (CI 2.3–14.8)
respectively. The proportions of all three diagnostic classifications
TA B L E 3   Index of Dental Anxiety and Fear (IDAF 4C+) in people were significantly higher than the general Australian population
experiencing homelessness compared to Australia population
(n  =  1,084) with 4.9% (CI 3.6–6.7), 2.2% (CI 1.4–3.5) and 0.9% (CI
norms
0.4–2.0) respectively.
Homeless Table 4 reports dental anxiety levels (classified by the DAQ) by
population Australian norm
demographic and oral health characteristics of the participants. The
M (95% CI) M (95% CI)
proportion of those with high dental anxiety did not differ signifi-
Fear module (n = 62) 18.02 (15.59, 14.40 (13.93,
cantly between demographic and oral health factors. Higher propor-
20.44) 14.86)a,b 
tions of participants who had poor self-rated oral health reported
Stimulus module (n = 64)
high dental anxiety (32.6%, n = 15) than those who had good or bet-
Painful or 2.64 (2.26, 3.02) 2.67 (2.55, 2.78)c 
ter self-rated oral health (16.7%, n = 3). Those who self-rated their
uncomfortable
procedures oral function as poor also had a higher proportion of dental anxiety
b,c (33.3%, n = 10) compared to participants with good self-rated oral
Feeling embarrassed 2.27 (1.89, 2.64) 1.40 (1.33, 1.47)  
or ashamed function (23.5%, n = 8).

Not being in control of 1.83 (1.51, 2.15) 1.77 (1.67, 1.88)c 

what is happening
Feeling sick, queasy or 1.56 (1.28, 1.85) 1.43 (1.35, 1.51)c  4 | D I S CU S S I O N
disgusted
Numbness caused by 1.54 (1.25, 1.83) 1.74 (1.65, 1.84)c  This study reported the extent and nature of dental anxiety in a sam-
the anaestheticd  ple of Australian people experiencing homelessness. Using the DAQ,
Not knowing what the 1.94 (1.6, 2.28) 1.84 (1.74, 1.93)c  this study found a higher proportion of high dental anxiety in those
dentist is going to do
who experience homelessness compared to the Australian popula-
The cost of dental 3.09 (2.67, 3.52) 3.25 (3.11, 3.39)c  tion (Armfield et al., 2006). The IDAF-4C+ questionnaire also found
treatment
dental anxiety was experienced at a significantly greater extent in
Needles or injections 2.53 (2.11, 2.95) 2.71 (2.58, 2.85)c 
the homeless population compared to the general population. In all
Gagging or choking 1.81 (1.45, 2.17) 1.98 (1.86, 2.09)c  three categories of phobia, there was a significantly higher propor-
Having an 2.38 (1.95, 2.8) 1.99 (1.87, 2.11)c  tion of the homeless population experiencing dental phobias than
unsympathetic or
the Australian norm. International studies using MDAS have found
unkind dentist
similar findings to this study. Using the cut-off MDAS score of 19,
Phobia modulee  (n = 61)
the prevalence of highly dentally anxious people who are possibly
P-DENT 23.0 (13.8, 34.6) 4.9 (3.6, 6.7)b,c 
dentally phobic in Scotland (20%) and Belfast (27%) was higher com-
P-DSMR 13.1 (6.4, 23.2) 2.2 (1.4, 3.5)b,c 
pared to the UK normal population (11%; Beaton et al., 2018; Collins
P-DSMS 6.6 (2.3, 14.8) 0.9 (0.4, 2.0)b,c  & Freeman, 2007; Humphris, Dyer, & Robinson, 2009). A study con-
Abbreviations: CI, confidence interval; DSM-IV, Diagnostic and ducted in Belfast using MDAS also found a higher severity of dental
Statistical Manual of Mental Disorders 4th ed.; IDAF 4C+, Index of anxiety in the local homeless population with a higher mean score
Dental Anxiety and Fear; P-DENT, phobia with a dental component;
(12.5) for dental anxiety compared to the UK norm population mean
P-DSMR , dental phobia using relaxed DSM-IV criteria; P-DSMS, dental
phobia using strict DSM-IV criteria. score (10.36; Collins & Freeman, 2007; Humphris et al., 2009).
a
Armfield (2011). The higher proportions of dental anxiety and phobia may have be
b
Reports significant difference due to non-overlapping CIs. related to the previously reported mental health issues experienced
c
Armfield (2010a). by the homeless population (Department of Health & Ageing, 2013).
d
Reports n = 63 due to missing data. A census conducted in Australia 2008 found the prevalence for
e
Reports proportions (%) and 95% CI of the proportion in parenthesis. mental health issues was 54% in the homeless population compared
 |
2358       YOKOTA et al.

TA B L E 4   Level of anxiety measured by the Dental Anxiety Questionnaire compared to demographic and oral health factors (n = 64)

Low anxiety High anxiety

n (%) n (%) p-value

Age (years)
15–44 23 (85.2) 4 (14.8) 0.491
45+ 29 (78.4) 8 (21.6)
Gender
Male 28 (71.8) 11 (28.2) 0.986
Female 18 (72.0) 7 (28.0)
Indigenous status
Yes 4 (50.0) 4 (50.0) 0.141
No 42 (75.0) 14 (25.0)
Country of birth
Australia 33 (71.7) 13 (28.3) 0.969
Other 13 (72.2) 5 (27.8)
Highest level of education
Primary school or less 5 (55.6) 4 (44.4) 0.169
Secondary school (year 12) 25 (80.6) 6 (19.4)
Trade or technical education 5 (50.0) 5 (50.0)
Higher education (University) 11 (78.6) 3 (21.4)
Smoking status
Never a smoker 10 (66.7) 5 (33.3) 0.687
Former 9 (81.8) 2 (18.2)
Current daily smoker 27 (71.1) 11 (28.9)
Employment
Unemployed 42 (71.2) 17 (28.8) 0.674
Employed 4 (80.0) 1 (20.0)
Residence
Alone 7 (50.0) 7 (50.0) 0.792a 
With a friend or family member 12 (80.0) 3 (20.0)
Government supported/community housing 20 (83.3) 4 (16.7)
On the streets or emergency accommodation 6 (60.0) 4 (40.0)
Other 1 (100.0) 0 (0.0)
Self-rated oral health
Poor/fair 31 (67.4) 15 (32.6) 0.202
Good/very good/excellent 15 (83.3) 3 (16.7)
Self-rated oral function
Poor/fair 20 (66.7) 10 (33.3) 0.384
Good/very good/excellent 26 (76.5) 8 (23.5)
Oral hygiene frequency and cleaning
When I remember 2 (100.0) 0 (0.0) 0.501
Less than once a day 12 (80.0) 3 (20.0)
Once a day 17 (73.9) 6 (26.1)
Twice a day or more 15 (62.5) 9 (37.5)
Usual reason for visiting a dental professional
When there is a problem 30 (68.2) 14 (31.8) 0.499
Check-up 14 (77.8) 4 (22.2)
Other 2 (100.0) 0 (0.0)
(Continues)
YOKOTA et al. |
      2359

TA B L E 4   (Continued)

Low anxiety High anxiety

n (%) n (%) p-value

Last visit to a dental professional

Over 12 months ago 26 (72.2) 10 (27.8) 0.983
In the last 12 months 17 (70.8) 7 (29.2)
I can't remember/don't know 3 (75.0) 1 (25.0)
Plaque health
Healthy 34 (85.0) 6 (15.0) 0.242
Unhealthy 16 (72.7) 6 (27.3)
Calculus health
Healthy 34 (80.0) 6 (20.0) 0.862
Unhealthy 18 (81.8) 4 (18.2)
Gingival health
Healthy 32 (80.0) 8 (20.0) 0.609
Unhealthy 18 (81.8) 4 (18.2)
Decayed, missing, filled teeth scoreb 
Decayed 4.2 (4.8) 4.3 (4.7) 0.947
Missing 4.7 (5.9) 7.6 (5.0) 0.119
Filled 5.6 (4.5) 4.3 (4.5) 0.407
a
Reports Fisher's exact test.
b
Reports mean, standard deviation and an independent t-test.

to 20% in the general Australian adult population (Department of
Health & Ageing, 2013). A study previously conducted in Belfast
found those with a history of mental illness had higher dental anxiety
scores (as measured by the MDAS) compared to those without a his-
tory of mental illness (Collins & Freeman, 2007). Dental anxiety has
been suggested to be a sign of other pre-existing mental disorders
such as social phobia or obsessive compulsive disorder (Armfield &
Heaton, 2013). The link between mental health and dental anxiety
may be bi-direction, as people experiencing homelessness reported
feeling embarrassed or ashamed as an anxiety-inducing stimulus to
a greater extent than the Australian population. Interestingly, this
stimulus was the least anxiety inducing for the general Australian
population (J. Armfield,  2010a). The poorer overall self-rated oral
health by the homeless population may induce feelings of embar-
rassment or shame. International studies have also observed a higher
proportion of people experiencing homelessness who felt self-con-
sciousness and embarrassment compared to the general population
(Beaton et al., 2018). These feelings of embarrassment may be due
to poorer oral health, loss of dignity and other social phobias and
disorders (Palma & Nordenram, 2005). This highlights the differing
psychosocial aspect to dental anxiety experienced by the homeless
population and the possible impact their affected oral health can
have on their quality of life. Holistic care of patients experiencing
homelessness can be achieved by identifying and managing the spe-
cific underlying factors of the patient's dental anxiety (Armfield &
Heaton,  2013). Ensuring that dental practitioners have a sensitive
and non-judgemental approach towards their oral health status
would be imperative to relieving dental anxiety within appointments
(Appukuttan,  2016). A relationship between social workers, men-
tal health workers and dental practitioners may also be beneficial
in managing such factors and improving their access to dental care
(Goode, Hoang, & Crocombe, 2018; Stormon et al., 2018).
In both the homeless and general Australian populations, the
highest reported anxiety-inducing stimuli included cost, painful or un-
comfortable procedures and needles or injections (Armfield,  2011).
Cost was reported to be the most anxiety-inducing factor in both the
general and homeless population. Despite majority of the homeless
population being eligible for public dental care, this population have in-
creased difficulties in accessing appointments due to their lower health
literacy, transient and changing lifestyles, poor understanding of the
system and long waiting lists (Ford et al., 2014; Stormon et al., 2018).
Therefore, the high cost of private dental care may be perceived as
a barrier, with approximately two thirds of the homeless population
compared to one third of the general population, citing this reason for
avoiding or delaying dental care (Ford et al., 2014; Slade et al., 2004;
Stormon et al., 2018). Studies have shown that cost is also associated
with poorer oral health status and dental appointment attendance in
Australia (Jamieson, Mejía, Slade, & Roberts-Thomson, 2010; Slade
et al., 2004). Thus, the barrier arising from cost-inducing anxiety may
be related to these poorer oral health outcomes and dental visits.
No statistically significant difference was found in this study
between high dental anxiety and demographic and oral health fac-
tors and may have been due to the small sample size. However,
another study of the general Australian population using the DAQ,
found a higher proportion of anxiety was reported in females than
males (Armfield et al., 2006). Mean scores for dental anxiety were
 |
2360       YOKOTA et al.
also found to be significantly higher in females than males in a
study conducted on the homeless population in Scotland (Beaton
et  al.,  2018). The difference among genders has previously been
explained by females having a tendency to rate anxiety-inducing
perceptions as more threatening compared to males (Armstrong
& Khawaja,  2002). Females have been also found to have a
higher prevalence of general anxiety than males (Armstrong &
Khawaja,  2002). In the general Australian population, the high-
est proportion of high dental anxiety was found in the age group
40–64 years old (Armfield et al., 2006). The majority of the home-
less population in this study were in this age bracket, which may
also explain the higher extent and nature of dental anxiety in this
sample. Tailored interventions and support programs to manage
and reduce dental anxiety in this population are warranted to im-
prove access to dental care.
The generalisability of the findings in this study may have been
limited by the small sample size and caution taken when comparing
these findings to population norms. Those experiencing homeless-
ness are often difficult to survey and obtain a representative sample
with the ‘hidden population’ often having transient lifestyle. Within
the population, there are also different levels of social exclusion and
mental health illnesses experienced which may have also been a
factor impacting their dental anxiety levels. Future studies should
consider exploring social exclusion and the mental health of this
population. Social desirability bias could have also influenced self-re-
ported oral health and hygiene behaviour responses. However, valu-
able insight on the extent and nature of dental anxiety within this
population was determined and how this differed from the general
population.
Given the comparatively higher extent of dental anxiety in
this vulnerable population, it is imperative that clinicians are able
to identify dentally anxious patients by observing their body lan-
guage, behaviour, history of missed appointments or via question-
naire screening. Appropriate management techniques should be
implemented including psychotherapeutic and pharmacology in-
terventions (Jamieson et al.,  2010). Dental care should be tailored
according to individuals’ different psychosocial needs due to the dif-
ference in the nature of the dental anxiety they experience. There
is a need to shape a more sensitive approach to dental care for this
vulnerable population which can be achieved by further studies that
provide a voice to the homeless population to express their needs
and concerns regarding oral healthcare (Beaton et al., 2018).
5 |  CO N C LU S I O N
High dental anxiety and phobia were more prevalent within the
Australian homeless population compared to the general Australian
population. Dental anxiety was experienced to a greater severity and
the nature of dental anxiety also differed with greater feelings of
embarrassment and shame experienced by the homeless population
in comparison to the general population. No significant associations
were found between high dental anxiety and demographic and oral
health factors in this study, possibly due to difficulties in surveying
this vulnerable population. A sensitive and multidisciplinary approach
to dental care for people experiencing homelessness is needed
to overcome the barrier of dental anxiety in accessing dental care.
Mental health and social exclusion should be explored in relation
to the dental anxiety of those experiencing homelessness in future
studies.
C O N FL I C T O F I N T E R E S T
The authors have no conflicts of interest to declare.
ORCID
Nicole Stormon  https://orcid.org/0000-0003-0758-1605
REFERENCES
Adams, R. J., Appleton, S. L., Hill, C. L., Dodd, M., Findlay, C., & Wilson, D.
H. (2009). Risks associated with low functional health literacy in an
Australian population. Medical Journal of Australia, 191(10), 530–534.
https://doi.org/10.5694/j.1326-5377.2009.tb033​0 4.x
Appukuttan, D. P. (2016). Strategies to manage patients with dental
anxiety and dental phobia: Literature review. Clinical, Cosmetic and
Investigational Dentistry, 8, 35. https://doi.org/10.2147/CCIDE.
S63626
Armfield, J. (2010a). The extent and nature of dental fear and phobia
in Australia. Australian Dental Journal, 55(4), 368–377. https://doi.
org/10.1111/j.1834-7819.2010.01256.x
Armfield, J. M. (2010b). Development and psychometric evaluation
of the Index of Dental Anxiety and Fear (IDAF-4C+). Psychological
Assessment, 22(2), 279. https://doi.org/10.1037/a0018678
Armfield, J. M. (2011). Australian population norms for the Index of
Dental Anxiety and Fear (IDAF-4C). Australian Dental Journal, 56(1),
16–22. https://doi.org/10.1111/j.1834-7819.2010.01279.x
Armfield, J. M., & Heaton, L. (2013). Management of fear and anxiety in
the dental clinic: A review. Australian Dental Journal, 58(4), 390–407.
https://doi.org/10.1111/adj.12118
Armfield, J. M., Spencer, A., & Stewart, J. F. (2006). Dental fear in
Australia: Who's afraid of the dentist? Australian Dental Journal, 51(1),
78–85. https://doi.org/10.1111/j.1834-7819.2006.tb004​05.x
Armfield, J. M., Stewart, J. F., & Spencer, A. J. (2007). The vicious cycle
of dental fear: Exploring the interplay between oral health, service
utilization and dental fear. BMC Oral Health, 7(1), 1. https://doi.
org/10.1186/1472-6831-7-1
Armstrong, K. A., & Khawaja, N. G. (2002). Gender differences in anx-
iety: An investigation of the symptoms, cognitions, and sensitivity
towards anxiety in a nonclinical population. Behavioural and Cognitive
Psychotherapy, 30(2), 227–231. https://doi.org/10.1017/S1352​46580​
2002114
Australian Bureau of Statistics. (2016). Census community profiles: Brisbane.
Retrieved from https://quick​stats.censu​sdata.abs.gov.au/census_servi​
ces/getpr​oduct​/censu​s/2016/commu​nityp​rofil​e/3GBRI
Australian Bureau of Statistics. (2018). Census of population and housing:
Estimating homelessness, 2016. Retrieved from https://www.abs.gov.
au/ausst​ats/abs@.nsf/looku​p/2049.0
Australian Health Ministers’ Advisory Council. (2015). Healthy mouths,
healthy lives: Australia’s National Oral Health Plan 2015–2024.
Canberra, ACT: Oral Health Monitoring Group: COAG Health
Council.
Beaton, L., Coles, E., & Freeman, R. (2018). Homeless in Scotland: An oral
health and psychosocial needs assessment. Dentistry Journal, 6(4), 67.
https://doi.org/10.3390/dj604​0 067
Brennan, D., Luzzi, L., Ellershaw, A., & Peres, M. (2019). Oral health per-
ceptions. In ARCPOH (Ed.), Australia's Oral Health: National study of
YOKOTA et al.
adult oral health 2017–18 (pp. 125–135). Adelaide, SA: The University
of Adelaide.
Collins, J., & Freeman, R. (2007). Homeless in North and West Belfast:
An oral health needs assessment. British Dental Journal, 202(12), E31.
https://doi.org/10.1038/bdj.2007.473
Council of Australian Governments, Refor Council. (2014). Healthcare
in Australia 2012-13: Five years of performance. Canberra: Australia:
Australian Government.
Department of Health and Ageing. (2013). National Mental Health report
2013: Tracking progress of mental health reform in Australia 1993–2011.
Canberra, ACT: Commonwealth of Australia Canberra.
Ford, P. J., Cramb, S., & Farah, C. S. (2014). Oral health impacts and qual-
ity of life in an urban homeless population. Australian Dental Journal,
59(2), 234–239. https://doi.org/10.1111/adj.12167
Goode, J., Hoang, H., & Crocombe, L. (2018). Homeless adults’ access
to dental services and strategies to improve their oral health: A sys-
tematic literature review. Australian Journal of Primary Health, 24(4),
287–298. https://doi.org/10.1071/PY17178
Humphris, G. M., Dyer, T. A., & Robinson, P. G. (2009). The modified den-
tal anxiety scale: UK general public population norms in 2008 with
further psychometrics and effects of age. BMC Oral Health, 9(1), 20.
https://doi.org/10.1186/1472-6831-9-20
Jamieson, L. M., Mejía, G. C., Slade, G. D., & Roberts-Thomson, K. F.
(2010). Risk factors for impaired oral health among 18-to 34-year-old
Australians. Journal of Public Health Dentistry, 70(2), 115–123.
Neverlien, P. O. (1990). Assessment of a single-item dental anxiety ques-
tion. Acta Odontologica Scandinavica, 48(6), 365–369. https://doi.
org/10.3109/00016​35900​9029067
Palma, P. D., & Nordenram, G. (2005). The perceptions of homeless peo-
ple in Stockholm concerning oral health and consequences of dental
treatment: A qualitative study. Special Care in Dentistry, 25(6), 289–
295. https://doi.org/10.1111/j.1754-4505.2005.tb014​03.x
Ramfjord, S. P. (1967). The Periodontal Disease Index (PDI). Journal of
Periodontology, 38(6 Part II), 602–610. https://doi.org/10.1902/
jop.1967.38.6_part2.602
Schuller, A. A., Willumsen, T., & Holst, D. (2003). Are there differences
in oral health and oral health behavior between individuals with high
|
      2361
and low dental fear? Community Dentistry and Oral Epidemiology,
31(2), 116–121. https://doi.org/10.1034/j.1600-0528.2003.00026.x
Segal, D. L. (2010). Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR). The Corsini Encyclopedia of Psychology, 1–3. https://doi.
org/10.1002/97804​70479​216.corps​y 0271
Seligman, L. D., Hovey, J. D., Chacon, K., & Ollendick, T. H. (2017). Dental
anxiety: An understudied problem in youth. Clinical Psychology
Review, 55, 25–40. https://doi.org/10.1016/j.cpr.2017.04.004
Slade, G. D., Spencer, A. J., & Roberts-Thomson, K. F. (2004). Australia’s
dental generations. The National Survey of Adult Oral Health, 6(2007),
274.
Stormon, N., Pradhan, A., McAuliffe, A., & Ford, P. J. (2018). Does a fa-
cilitated pathway improve access to dental services for homeless
and disadvantaged adults? Evaluation Program Planning, 71, 46–50.
https://doi.org/10.1016/j.evalp​rogpl​an.2018.08.002
Thomson, W. M., Stewart, J. F., Carter, K. D., & Spencer, A. J. (1996).
Dental anxiety among Australians. International Dental Journal, 46(4),
320–324.
S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Yokota K, Yu SW, Tan T, Anderson J,
Stormon N. The extent and nature of dental anxiety in
Australians experiencing homelessness. Health Soc Care
Community. 2020;28:2352–2361. https://doi.org/10.1111/
hsc.13056