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CLINICAL
PRACTICE
increasingly important component of dental education and research.1,2 One component of this has
been the application of psychological methods to
the study of behavior and attitudes relevant to
health, illness and health carein particular,
fear of dentists and dentistry as well as of dental
pain. This has included a wide range of methodological approaches and techniques, especially
the use of questionnaires and behavioral measures. Several authors have emphasized the
importance of ensuring that such measures are
reliable, valid and applicable to the population
toward which they are aimed.3,4 We seek to provide an overview of measures of anxiety and pain
in dental research during a 10-year period and
an appraisal of the psychometric properties of
the measures used. We hope that this will serve
two functions: to help researchers choose suitable
measures when undertaking studies of behavior
in dentistry, and to identify areas in which
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little published evidence on
which to compare the utility
of measures of pain in dental
settings.
MATERIALS AND
METHODS
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The use of
questionnaire
measures of anxiety
in dentistry is wellestablished.
bility and validity, the terms
satisfactory and high are
used to refer to the following
criteria. For internal consistency, measured by Cronbachs ,
satisfactory is used when the
value of is greater than .60;
high is used when is greater
than .80. For test-retest correlations, a value of r > .80 is
rated as satisfactory and a
value of r > .90 as high. For
interscale correlations used to
determine the validity of a
scale, r > .60 is considered satisfactory and r > .80 is considered high.
RESULTS
We performed computerized
searches of the dental literature
published in a 10-year period to
identify all studies in which
questionnaire measures of psychological constructs had been
included. We reviewed the articles to identify the scales that
had been used. We then examined the primary sources to
identify the psychometric
properties of the measures
identified.
Search strategy. A complete description of the search
mechanism used is found elsewhere.8 We searched the MEDLINE, EMBASE and SSCI
databases for a 10-year period
from July 1988 through June
1998. For the purposes of this
article, only studies that included measures of anxiety or pain
will be revieweda total of 43
reports. We identified a total of
15 questionnaires in 38 articles
that measured dental anxiety
and three questionnaires in
eight articles that measured
dental pain and pain behaviors.
Data gathered. We gathered specific information on
each scaleinsofar as it was
possibleusually from sources
referenced in the articles. Articles, books and other materials
containing this information that
were published before our review period were included to
obtain a complete picture of the
qualities of the scale. Furthermore, cited articles were not
restricted to the dental literature and included research in
medicine and psychology.
The information we collected
CLINICAL PRACTICE
TABLE 1
NUMBER OF ARTICLES IN
WHICH SCALE IS CITED
(N = 38)*
Adult Dental Scales
Corahs Dental
Anxiety Scale9
35
Modified Dental
Anxiety Scale16
Kleinknechts
Dental Fear
Survey17
Dental Anxiety
Question19
Gatchels
10-Point Fear
Scale22
Photo Anxiety
Questionnaire23
Dental Anxiety
Inventory25
Venham Picture
Scale29
Venham Anxiety
and Behavior
Rating Scales30
Adolescents
Fear of Dental
Treatment
Cognitive
Inventory32
Behavior
Profile Rating
Scale33
Fear Survey
Schedule36
Weiner Fear
Questionnaire40
* During the period from 1988 through 1998. The total is greater than 38 since studies
used more than one measure of dental anxiety.
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phrases do not arise, andprovided that the facial expressions depicted are universal
difficulties in translating
responses do not arise. De
Jongh and Stouthard24 used
this scale to analyze the degree
of anxiety experienced by
patients receiving treatment
from a dental hygienist.
Dental Anxiety Inventory.25
The Dental Anxiety Inventory,
or DAI, is a 36-item scale.
Answers are given on a fivepoint scale, and scores range
from 36 (no anxiety) to 180
(high anxiety). The internal
consistency of the scale is high
( = .95 for a student popula-
CLINICAL PRACTICE
overall score is calculated on
the basis of the frequency of
each behavior, together with a
weighting for the severity of the
behavior (for example, kicking
is perceived to be more severe
than oral complaints). The scale
has adequate interrater reliability, given adequate training
of observers. The face validity
of the scale is high, and it has
been found to distinguish between children referred for
behavioral management of
uncooperative behavior in the
dental setting and a control
group of children.31 As with
many behavioral measures, use
of this scale is likely to be timeconsuming.
Spielbergers
State-Trait Anxiety
Inventory
distinguishes
between anxiety as
a general aspect of
personality and
anxiety as a
response to a
specific situation.
General adult scales.
Spielbergers State-Trait
Anxiety Inventory.34 Spielbergers State-Trait Anxiety
Inventory, or STAI, distinguishes between anxiety as a general
aspect of personality (trait anxiety) and anxiety as a response
to a specific situation (state
anxiety). It consists of 40 statements, 20 of which measure
trait anxiety and 20 state anxiety. Items are scored on fourpoint scales, with response categories varying according to the
nature of the question. This
questionnaire has been tested
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TABLE 2
NO. OF
ITEMS
TARGET
POPULATION
RELIABILITY
VALIDITY
AVAILABILITY
OF NORMS
General
Population
Clinical
Population
COMMENTS
Adults
Modified Dental
Anxiety Scale
Adults
27
Adults
Dental Anxiety
Question
Adults
Tends to overestimate
severe dental anxiety.
Gatchels
10-Point Fear
Scale
Adults
Photo Anxiety
Questionnaire
10
Adults
Dental Anxiety
Inventory
36
Adults
Childrens
Fear Survey
Schedule
15
Children
Venham Picture
Scale
Children
Venham Anxiety
and Behavior
Rating Scales
Children
Adolescents
Fear of Dental
Treatment
Cognitive
Inventory
23
Adolescents
Behavior Profile
Rating Scale
21
Children
Behavioral scale.
Resource-intensive
(requires an observer).
40 (12)
Adults
51 (18)
Adults
Weiner Fear
Questionnaire
16
Adults
McGill Pain
Questionnaire
11
Adults
NA
West Haven-Yale
Multidimensional Pain
Inventory
12
Adults
NA
Designed to be used in
cases of chronic pain.
Pain Anxiety
Symptoms Scale
10
Adults
Kleinknechts
Dental Fear
Survey
Spielbergers
State-Trait
Anxiety
Inventory
Fear Survey
Schedule
Nonverbal response
format.
: Information available.
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Corahs Dental
Anxiety Scale
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length and content. Both anxiety and pain are multidimensional constructs, and it is
important to identify which
dimensions are being assessed.
Furthermore, the use of standardized instruments provides
the opportunity for comparison
of data across groups, experimental manipulations and
treatment approaches.
CONCLUSIONS
CLINICAL PRACTICE
20. Milgrom P, Fiset L, Melnick S,
Weinstein P. The prevalence and practice
management consequences of dental fear in a
major U.S. city. JADA 1988;116:641-7.
21. Neverlien PO. Dental anxiety, optimism-pessimism, and dental experience from
childhood to adolescence. Community Dent
Oral Epidemiol 1994;22:263-8.
22. Gatchel R. The prevalence of dental fear
and avoidance: expanded adult and recent
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23. Stouthard ME, De Jongh A,
Hoogstraten J. Dental anxiety: the use of
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24. De Jongh A, Stouthard ME. Anxiety
about dental hygienist treatment. Community Dent Oral Epidemiol 1993;21:91-5.
25. Stouthard ME, Hoogstraten J. Prevalence of dental anxiety in the Netherlands.
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26. Scherer MW, Nakamura CY. A fear survey schedule for children (FSS-FC): a factor
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(CMAS). Behav Res Therapy 1968;6:
173-82.
27. Cuthbert MI, Melamed BG. A screening
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30. Venham L, Gaulin-Kremer E, Munster
E, Bengston-Audia D, Cohan J. Interval rating scales for childrens dental anxiety and
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31. Alwin NP, Murray JJ, Britton PG. An
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34. Spielberger C, Gorsuch R, Lushene R.
STAI manual for the State-Trait Anxiety
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35. Marteau T, Bekker H. The development
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