Assessing children’s dental anxiety:A systematic review of current measures

1Porritt, J. , 2Buchanan, H., 1Hall, M., 1Gilchrist, F. & 1Marshman, Z.

Running head: A systematic review of children's dental anxiety measures

1 Academic Unit of Oral Health and DevelopmentSchool of Clinical DentistryUniversity of SheffieldClaremont CrescentS10 2TA

2 Institute of Work, Health & OrganisationsInternational HouseJubilee CampusWollaton RdNottingham NG8 1BB

1

Abstract

Objectives: The reliable assessment of children’s dental anxiety can have many

benefits for the dental team, service providers and dental public health practitioners.

This study aimed to identify and evaluate self-report measures which are available to

assess children’s dental anxiety.

Methods: Systematic searches of the literature between 1998 and 2011 were

conducted to identify relevant studies. The properties of each measure (reliability and

validity) were assessed and measures were evaluated against a theoretical framework

of dental anxiety.

Results: Executing the search strategy generated 498 articles and of these 60 studies

met all of the inclusion criteria. Seven ‘trait’ and two ‘state’ measures of dental anxiety

had been employed to assess children’s dental anxiety over the past decade.

Reliability and validity estimates for the most widely used measures were good,

however, many questionnaires had a limited focus in the aspects of anxiety they

assessed.

Conclusions: The paper summarises the measures of children’s dental anxiety which

may be most useful for a number of different purposes and populations.

2

Introduction

Dental anxiety is a common problem which develops mostly in childhood and

adolescence . Approximately half of children report low to moderate dental anxiety

and between 10% and 20% report high levels of dental anxiety . It should be

recognised that the nature of a child’s dental anxiety can vary significantly and whilst

some children present with fears or phobias in relation to specific dental stimuli (e.g.

needle or drill) other children report more generalised anxiety associated with the

dental setting .

In practice differentiating dental anxiety, fear and phobia is complicated and these

terms are often used interchangeably within the literature . Classified under the

umbrella of anxiety disorders, a phobia is a clinical diagnosis and refers to a marked

fear which interferes with a person’s normal routine, whereas fear is not always

extreme . However, the term dental anxiety is often used to include all different types

of dental fears and phobias.

Dental anxiety can have major implications for the child, dental team and dental

services. Children with high levels of dental anxiety have increased numbers of

decayed, missing and filled tooth surfaces compared with children who have low levels

of dental anxiety . Providing treatment for a dentally anxious patient can be time

consuming, costly and demanding for the clinician . These factors may result in

children being referred to secondary dental care services and having to wait longer

periods of time for their dental treatment. Indeed, anxious children are one of the key

groups that are seen by specialist services .

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The way in which dental anxiety develops has received much of the attention within

the dental anxiety literature, however, it is also important to understand how children’s

anxiety is being maintained over time as symptoms of anxiety can intensify into

adulthood . It is recognised that dental anxiety can be maintained through a cycle

whereby bodily arousal, cognitive interpretation and ineffective behavioural coping

strategies work in a feedback loop . The Five Areas Model of anxiety is a theoretical

framework based on a cognitive behavioural model, which outlines how an individual’s

i) thoughts ii) feelings iii) behaviours iv) physical symptoms and v) situation are all

inter-related and can contribute to increased feelings of anxiety. Using this model the

appropriate psychological treatment can be identified and aspects of the child’s anxiety

which are maintaining their fear (e.g. unhelpful thoughts, unhelpful behaviours)

targeted.

On consideration of the evidence which links dental anxiety with poor oral health

outcomes it is important that children with dental anxiety are identified from an early

stage and that the prevalence of dental anxiety, and its impact in a population, is

established and monitored. Three broad methods of assessing children’s dental

anxiety include: i) direct observation of the child’s physiological state or behavioural

response in the dental context (usually by either dental personnel and/or researchers)

ii) the completion of a questionnaire by the parent as a proxy measure of how anxious

the child is and iii) self-report scales completed by the child . Using clinical

observations alone is not reliable with studies showing that there is poor to moderate

agreement when dentists’ ratings are compared to the child’s own anxiety ratings .

Whilst children with dental anxiety may be more likely to exhibit negative emotional

and behavioural reactions within the dental encounter , some children do not display

overt presentations of anxiety and behavioural reactions sometimes interpreted as

manifestations of anxiety can be due to other factors, such as behavioural 4

management problems. Moreover, physiological responses have been questioned in

terms of validity and some forms of physiological measurement (such as cortisol) can

be costly to analyse and are not appropriate for routine anxiety assessment in clinical

practice. Proxy measures also have limitations. It has been proposed that parents

often reflect their own anxiety, rather than reflecting the views of their children .

Previous research has revealed that parents are not able to reliably assess children’s

levels of dental anxiety with studies showing only moderate agreement between child

and parental ratings .

Overall, self-report measures of dental anxiety completed by the child themselves

(where this is feasible) are the most reliable and valid method of assessing anxiety

with many benefits for the dental team, service providers and dental public health

practitioners (Table 1). For example, dental anxiety measures can be used for a

variety of purposes including determining population prevalence of dental anxiety,

measuring risk factors and symptoms in individuals and assessing changes in anxiety

over time (e.g. pre-post treatment interventions) .

Research has revealed that children aged eight-years-old and over can reliably report

on virtually all aspects of their health . Whilst children as young as three and four can

effectively communicate emotional and physical experiences such as pain there are

clear developmental differences in children’s abilities to understand and report on their

emotional and cognitive states . Therefore, for children to be able to accurately

complete self-report items measures must demonstrate developmental validity , which

means that children should be able to comprehend the questions and response

alternatives included within the measure. The child’s comprehension will be dependent

on the complexity of the language and specific terminology used within the measure.

For example, there is some evidence that the word ‘worried’ is understood by more 5

children, aged between five and seven years old, than the term ‘nervous’ . Therefore,

the way it which the current dental anxiety measures have been developed/modified

and tested with children of different age ranges and capabilities is an important area of

evaluation.

Rationale

Up-to-date information on the properties of the different self-report measures should

be made available if assessments of children’s dental anxiety are to be encouraged. It

has been proposed that researchers interested in dental anxiety should also be aware

of the dimensions of anxiety which are assessed by the different measures available .

Therefore, it is important to understand the way in which the construct of anxiety is

operationalised within the different measures when choosing the most appropriate

self-report dental anxiety measure to use . For example, if the purpose of assessment

is to inform clinical treatment planning, it may be important to assess the

multidimensional nature of the patient’s dental anxiety and examine factors which are

contributing the maintenance of their anxiety. In contrast if the main objective is to

collect information relating to the prevalence of dental anxiety in a particular group or

community then a reliable and valid measure which has established cut-off points may

be the priority. Ultimately, the recommended dental anxiety measure of choice will be

determined by the type of information the researcher, health care professional or

epidemiologist would like to obtain from the assessment.

Previous reviews which have evaluated self-report measures of dental anxiety were

published over ten years ago and since this time, new measures of dental anxiety

have been developed. Klinberg recently highlighted the need for paediatric dentists to

carry out assessments of children’s dental anxiety and provided an overview of the

different methods available . However, Schuurs and Hoogstraten, in their review of 6

adult dental anxiety measures, highlighted the importance of evaluating, in detail, the

aspects of dental anxiety which the different measures assess . Therefore, the aim of

this systematic review was to identify and evaluate self-report measures of dental

anxiety which have been used to assess children’s dental anxiety since the date of the

last systematic review in this area. Specific objectives included: i) providing a

descriptive account of each measure (e.g. number of items, scoring); ii) providing

information relating to the validity and reliability of each measure; iii) providing

information about the way in which these measures had been developed (e.g. level of

child involvement); iv) evaluating which aspects of dental anxiety they assess and v)

describing the study populations in which the different measures have been employed

(e.g. age ranges, countries). The findings of this review will help inform the choice of

such measures for dental practitioners, service providers and epidemiologists.

Materials and Methods

Design and search strategy

Titles and abstracts of all studies published between July 1998 and August 2010 using

Medline (via Pubmed) and 1998 – 2010 using Social Science Index Citation (via Web

of Science) were searched. The search terms used included child related keywords

(child* OR young OR young person OR minor* OR paediatric* OR pediatric*) AND

dental anxiety related key words (dental anx* OR dental fear* OR dental phobia* OR

odontophobia*). In order to be included within the review, studies had to have

employed measures of dental anxiety completed by children themselves (≤16 years),

been published in English and reported primary data. Studies which used proxy

measures of children’s dental anxiety were excluded. Single-item measures of dental

anxiety which had not been validated (no established reliability or validity estimates

available) and anxiety measures which were not dental-specific were also excluded.

7

A preliminary screening of the abstracts and titles, revealed by the search, enabled the

identification of potentially relevant studies. The reviewing team consisted of

professionals from a variety of disciplines (paediatric dentistry, health psychology,

dental public health and medical sociology). Pairs of trained reviewers from the team

independently applied the inclusion criteria when reviewing the abstracts and complete

papers. All papers that passed the abstract screening were retrieved in their complete

forms and data extraction was conducted. A standardised data extraction form

informed by previous reviews was developed, piloted and employed by the three pairs

of independent reviewers. There was ≥85% agreement between reviewers for study

inclusion when abstracts were reviewed and ≥90% agreement for study inclusion

when complete papers were reviewed. Disagreements were successfully resolved

through discussion.

The original validation papers, for all of the measures identified within the review, were

also consulted. The reliability and validity estimates and means reported in these

original research papers were included in the results unless the measures had been

validated with adult participants.

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Data collection

Data were extracted from the original articles, which described the development of the

self-report dental anxiety measures, and all of the studies which met the inclusion

criteria. Information related to the settings in which the different measures had been

employed (e.g. clinical and population) was collected. The mean scores and reports of

validity and reliability for each measure were also collected from these studies.

The validity of a questionnaire was typically assessed by examining how well the

measures correlated with a previously validated measure which assessed the same

construct (concurrent validity). Information relating to whether measures had been

developed/tested with children was also examined to evaluate the developmental

validity of the measures. The reliability of a questionnaire was assessed by examining

the internal consistency of the items included (e.g. Cronbach’s alpha) and the stability

of the questionnaire, when assessing a particular construct over time (e.g. test-retest

reliability). Information related to other aspects of each measure was also collected

which included: questionnaire length; response format; scoring method; and

established cut-off points. Details regarding the specific aspects of dental anxiety the

measures assess, as conceptualised by the Five Areas Model of anxiety (e.g.

thoughts, feelings, behaviours, physical symptoms, situational triggers), were also

examined and reported.

Results

Executing the search strategy generated 498 articles. Following the reviewers’

assessments of the abstracts, a total of 68 papers were identified as duplicates and

9

250 did not meet the sample criteria. Of the 180 abstracts which passed the abstract

screening, 179 were reviewed and one paper could not be obtained by the research

team. After obtaining the full papers a further 119 papers were excluded leaving a total

of 60 papers which met all of the study’s inclusion criteria (Figure 1).

Nine self-report measures of dental anxiety were employed within these studies.

Summary and key points for the nine measures are described in Table 2. Information

on the measures’ reliability, validity and areas assessed (e.g. thoughts, behaviours,

physical symptoms, feelings and situational triggers) are also presented in Table 3.

Means and reliability/validity estimates reported in studies which used modified

versions of measures (e.g. reduced number of items or altered scoring procedures)

were not reported.

Unless indicated otherwise, the scales described below are ‘trait’ measures. Generally

‘state’ measures can only be employed in the dental context (e.g. in the dental waiting

room/in the dental chair) as they are purporting to measure how the child feels at that

moment in time whereas ‘trait’ measures can be employed out of the dental context

and assess the child’s dental anxiety across a variety of dental contexts or procedures.

The Children’s Fear Survey Schedule Dental Subscale (CFSS- DS)

The CFSS-DS measure was the most popular measure of dental anxiety used to

assess children’s dental anxiety, employed in 28 studies. This self-report measure was

developed from the Fear Survey Schedule for Children, a 80 item questionnaire

designed to assess a variety of children’s fears and anxieties . The CFSS-DS is a

dental specific measure which requires children to rate how frightened they are in

response to 15 dental-related situations/treatments (e.g. ‘dentists’, ‘injections’ and

‘having somebody examine your mouth’). The CFSS-DS was found to have high 10

reliability and established cut-off points. The measure has also been used with a wide

age range of children. However, the measure does not assess the physical reactions,

thoughts and behaviours which may contribute to children’s dental anxiety. It should

also be noted that some of the specific situations assessed within the measure are not

highly relevant to dental anxiety (e.g. ‘doctors’). Whilst the measure was developed for

children there is no evidence (from examination of the original article describing the

development of this questionnaire) that children were involved in the development of

this measure. It should also be noted that a number of studies which have used this

measure have dropped several of the original items to create a shorter version of the

questionnaire, making data comparability difficult .

Dental Fear Schedule Subscale Short Form (DFSS-SF)

The DFSS-SF was used in seven studies. The measure is a shorter version of the

CFSS-DS measure containing eight items and asks children to rate how frightened

they would feel in response to eight specific dental-related situations/treatments. The

measure shares some of the advantages of the CFSS-DS and the reduced number of

items means that the measure has the added advantage of being quicker to complete

than the CFSS-DS. Another advantage of the DFSS-SF is that items which are not

highly relevant to dentistry (e.g. ‘doctors’) have been removed from this shortened

questionnaire. However, the measure shares a number of the drawbacks of the CFSS-

DS, which have previously been described.

Dental Anxiety Scale (DAS) and Modified DAS

The DAS was used in thirteen studies and one study employed the Modified DAS .

The DAS is a four-item measure and the MDAS a five item measure, both were

developed to assess dental anxiety in adults. Participants indicate how relaxed or

anxious they feel about four dentally related situations (e.g. ‘If you had to go to the 11

dentist tomorrow for a check-up, how would you feel about it?’) by choosing from a

series of responses (e.g. ‘relaxed’, ‘I would look forward to it as a reasonably

enjoyable experience’). This measure explores the situational triggers of dental anxiety

and physical reactions experienced by dentally anxious individuals. Pictorial response

formats have also been used with the DAS . For example, the Facial Image Scale has

been combined with the DAS to produce the combined dental anxiety scale (COM-

DAS) . Whilst studies employing these measures have reported high reliability

estimates, these measures were developed to assess adult’s dental anxiety so the

instructions, items and response format may not be appropriate for children. No

validity estimates were available for the measure when employed with child

participants and the measure does not assess the unhelpful thoughts or behaviours

which may be contributing to the child’s dental anxiety

Modified child dental anxiety scale (MCDAS)

The MCDAS was used in ten studies and contains eight questions, four of which are

based on the original DAS. The additional anxiety-provoking dental situations

assessed by the MCDAS include dental injections, general anaesthesia, extraction

and sedation. Children were involved in developing a child appropriate response

format for the MCDAS. The measure assesses the child’s general level of dental

anxiety and seven possible situational triggers of dental anxiety. Reliability and validity

estimates suggest that internal reliability is high and the measure is able to

discriminate between children with and without dental anxiety . There is also a faces

version of the MCDAS (MCDASf) which incorporates faces (similar to the Facial

Image Scale but the final face on this scale is crying) within the response format. The

faces version of the measure was developed to be more suitable for children as young

as three years old and those with limited cognitive functioning . However, the MCDAS

does not assess unhelpful thoughts, behaviours or physical reactions which may be 12

contributing to children’s dental anxiety and the two questions it contains on

sedation/anaesthesia may limit its possibilities in situations where the child is

unfamiliar with these procedures.

Facial Image Scale (FIS)

The FIS comprises one item with a response set of five faces (ranging from a very sad

to a very smiley face). Children are asked to indicate which of the faces they feel most

like at that moment; thus it is a ‘state’ measure of anxiety. The FIS has been used as a

standalone measure and as response set for the MCDAS and CDAS measures . The

FIS was developed to allow for limited cognitive and linguistic skills of younger children

and provides an immediate reflection of how the child is feeling, which may be useful

for clinicians. However, when assessing the face validity of the measure it could be

argued that the item may assess the child’s mood at that point in time, rather than their

‘state’ dental anxiety. The measure also does not assess specific triggers of dental

anxiety or potential unhelpful thoughts, behavioural or physical reactions which may be

contributing to the child’s anxiety. No reliability estimates are available for this

measure, (as it is a one ‘item’ state measure), however, the measure has been found

to be significantly correlated with the Venham Picture Scale indicating concurrent

validity .

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Venham Picture Scale (VPS)

The VPS is a pictorial measure of dental anxiety which was employed in four of the

included studies. This ‘state’ measure incorporates eight pictures with each depicting

two cartoon boys displaying contrasting emotions. The participant is required to

indicate which of the boys, within the eight pictures, most accurately reflect their

feelings at that time. The measure was developed to be suitable for children as young

as three so the use of pictures alleviates the need for children to possess developed

language skills, with children being able to respond to the measure nonverbally. One

of the main disadvantages of the measure is that some of the emotions displayed in

the eight pictures are ambiguous (i.e. it is unclear what behaviour/feelings they are

displaying) . This ‘state’ measure does not explore possible situational triggers of

dental anxiety nor does it have established cut-off points to help administrators of the

questionnaire distinguish between anxious and non-anxious children. Internal

consistency of the pictures is high, however, there is no information relating to the

validity of the measure.

Dental Fear Survey (DFS, 20-item version) and modified version of the DFS

The Dental Fear Survey was originally a 27-item questionnaire developed to assess

dental anxiety in adults and was later revised to a 20-item measure of dental anxiety .

The revised 20 item measure was used in two of the reviewed studies and a further

modified 15 item questionnaire has also been used to assess children’s responses to

a variety of dental situations (e.g. ‘sight of injection’ and ‘feeling the drill’) and general

fear of dentistry. The 20 item DFS had excellent internal consistency when used with

children aged between eight and eighteen. However, some of the situational triggers

may not be relevant to children (e.g. ‘making a dental appointment’). Whilst the

questionnaire does not assess unhelpful thoughts children may experience it does

14

assess a variety of unhelpful behaviours (e.g. ‘failed to appear for a dental

appointment’) and physical reactions (e.g. ‘muscle tenseness’) which may be

contributing to children’s dental anxiety.

Smiley Faces Programme (SFP) and Revised SFP

Two validation studies report on the properties of the SFP and SFP-R, which are fully

computerised measures incorporating items derived from the Modified Dental Anxiety

Scale . The measures include a seven item facial image scale as an interactive

response format. The original SFP measure requires children to indicate how they

would feel in response to four dental scenarios (e.g. ‘Having to have dental treatment

the following day’) and the Revised SFP includes an additional dental scenario (‘about

to have a tooth out’). Both the SFP and Revised SFP were piloted with children and

revisions were made to the measures based on children’s suggestions and

experiences. The interactive nature of the measure could appeal to both child

patients/participants and researchers. However, the use of this measure relies on

computer access and unhelpful behaviours, thoughts and physical reactions, which

may be contributing to the child’s anxiety, are not assessed.

Short version of the Dental Anxiety Inventory (S-DAI) .

The S-DAI was employed by only one of the studies included within the review. The

measure includes nine items and requires respondents to indicate their level of

agreement with a number of dental related statements (e.g. ‘When I know the dentist

is going to extract a tooth I am already afraid in the waiting room’ and ‘As soon as the

dentist gets his/her needle ready for the anaesthetic, I shut my eyes tight’). One of the

main advantages of the measure is that it takes into account different situations and

treatments which may trigger dental anxiety, whilst assessing physical reactions,

thoughts and behavioural aspects of dental anxiety experienced by the individual. 15

However, the questionnaire was developed as an adult measure of dental anxiety and

so it is proposed that the lengthy scenarios described and response format may not be

suitable for (younger) children. No reliability and validity estimates were available for

the measure when employed with child participants.

Discussion

The review revealed nine self-report measures of dental anxiety had been employed to

assess children’s dental anxiety over the past decade. The previous review conducted

in 1998 identified only three self-report measures of children’s dental anxiety and,

therefore, there has been a larger pool of scales available for researchers and

clinicians to choose from in recent years. Anxiety can be measured for a number of

different purposes and populations (as highlighted in Table 1) and as such a ‘one size

fits all’ measure is not always appropriate. Below, we summarise which measures may

be most useful for clinical, service organisation, survey or research purposes.

At a patient level, a trait measure administered at a new patient appointment may help

identify patients with high levels of anxiety and/or specific dental fears. Practitioners

may consider using the findings for treatment planning and as a communication tool.

The desirable properties of a measure to assess dental anxiety in this setting would be

i) short, to allow it to be completed in the waiting room; ii) suitable for a wide range of

ages; iii) contains a variety of questions related to specific dental procedures, and iv)

developed with children to ensure that response formats are clear and that the items

used are valid. Therefore, measures such as MCDAS/MCDASf and SFP (though a

computer would be required for this measure) may be particularly useful in this setting.

The Dental Fear Survey assesses multiple aspects of the child’s anxiety (e.g.

behaviours) and so this may also be desirable. Though a slighter longer measure (20

items), the DFS has been found to be a valid and reliable measure of anxiety in 16

children over the age of 8 years old. If the clinician wants an immediate reflection of

how the child is feeling, then a state measure such as the Facial Image Scale may be

appropriate as it is immediate, easy to administer and score and can be used with

even very young children. However, it should be noted that this measure (and others

like it) is limited in the information it provides to the practitioner.

Choosing a measure for survey or research purposes will depend on the research

question being tested. However, such studies should demonstrate that the scale

employed has good reliability and validity. Measures such as the MCDAS, CFSS-DS

and DAS/MDAS have demonstrated acceptable psychometric properties and been

employed in previous longitudinal and experimental studies .

At a service organisation level a valid and reliable trait measure with established cut-

offs is desirable, to enable practitioners to make appropriate referrals and so that

providers and commissioners can plan for the numbers of highly anxious patients

referred to secondary care services. Measures such as the MCDAS and CFSS-DS

may be helpful for this purpose, though it should be noted that younger children may

need help with understanding some of the items and response format. The faces

version of the MCDAS may be helpful for younger patients, although very young

children will still need to be assisted with completion.

It should be recognised, however, that many of the self-report measures which have

been used with children had a limited focus (e.g. situational triggers of dental anxiety)

and have not been based on a theoretical framework of dental anxiety. The lack of

consideration of the theoretical underpinnings of dental anxiety has previously been

highlighted with reference to measures of dental anxiety . The Five Areas Model of

anxiety highlights the interrelationship between an individual’s unhelpful thoughts, 17

physical symptoms, behaviours, feelings and situational factors (e.g. parental anxiety)

and the importance of assessing these different aspects of dental anxiety . Indeed, if a

child’s dental anxiety is to be treated then it has been argued that the factors which

contribute to their dental anxiety need to be understood . Measures which only assess

a specific component of dental anxiety may produce an incomplete picture of an

individuals’ anxiety . The DFS and S-DAI were the only measures employed which

assessed multiple aspects of children’s dental anxiety (e.g. unhelpful thoughts,

behaviours and physical symptoms).

In addition, five of the measures used to assess children’s dental anxiety had either

fully or partially been developed to assess the dental anxiety of adults. Many of the

early measures of child health-related quality of life were also adapted from adult

measures with concerns later expressed about their validity as the items included and

language used were not found to be relevant or appropriate for children . Further

examination of the content and developmental validity (i.e. whether the measures,

comprehensively cover the domain of interest and make sense to child participants) of

measures of child dental anxiety are required. Cognitive interviewing techniques such

as the ‘think aloud’ procedure, which involves asking children to verbalise their

thoughts whilst responding to questionnaire items , could be used to test how well

children of different ages are able to understand and complete measures of dental

anxiety.

It should also be noted that none of the studies reviewed employed measures of

dental anxiety with children who have learning disabilities. This patient group may

experience particular difficulty expressing their fears and articulating their concerns.

Previous research has identified that individuals with learning disabilities do report

notable anxieties relating to dental examinations and treatments such as being afraid 18

of losing control and having difficulty complying with instructions . The development of

an anxiety measure for children with learning disabilities could serve as a valuable

communication aid and promote effective child-centred management of dental anxiety

in this group of patients.

Conclusion

To conclude, dental anxiety and fear-related behaviours in children provide challenges

for clinicians and dental public health practitioners. With a need for a clear

understanding of the severity and nature of children’s dental anxiety the findings from

this systematic review can be used to help guide dental academics, clinicians,

psychologists and epidemiologists choose the most appropriate measure of dental

anxiety for their intended use. Future work should involve evaluating the content and

developmental validity of existing measures with further consideration given to the use

of theoretical frameworks to develop this field.

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References

1. Locker, D., et al., Age of onset of dental anxiety. J Dent Res, 1999. 78(3): p. 790-6.2. Locker, D., W.M. Thomson, and R. Poulton, Onset of and patterns of change in dental anxiety in

adolescence and early adulthood: a birth cohort study. Community Dental Health, 2001. 18(2): p. 99-104.

3. Taani, D.Q., S.S. El-Qaderi, and E.S. Abu Alhaija, Dental anxiety in children and its relationship to dental caries and gingival condition. Int J Dent Hyg, 2005. 3(2): p. 83-7.

4. Dogan, M.C., et al., The effect of age, gender and socio-economic factors on perceived dental anxiety determined by a modified scale in children. Oral Health Prev Dent, 2006. 4(4): p. 235-41.

5. Rantavuori, K., et al., Dental fear and oral health and family characteristics of Finnish children. Acta Odontol Scand, 2004. 62(4): p. 207-13.

6. Peretz, B. and J. Efrat, Dental anxiety among young adolescent patients in Israel. Int J Paediatr Dent, 2000. 10(2): p. 126-32.

7. Rantavuori, K., et al., Dental fear of Finnish children in the light of different measures of dental fear. Acta Odontol Scand, 2005. 63(4): p. 239-44.

8. Ashkenazi, M., D. Faibish, and H. Sarnat, Dental fear and knowledge of children treated by certified pediatric dentists and general practitioners. ASDC J Dent Child, 2002. 69(3): p. 297-305, 235.

9. Armfield, J.M., How do we measure dental fear and what are we measuring anyway? Oral Health Prev Dent, 2010. 8(2): p. 107-15.

10. Nicolas, E., et al., Factors affecting dental fear in French children aged 5-12 years. International Journal of Paediatric Dentistry, 2010. 20(5): p. 366-373.

11. Akbay Oba, A., C.T. Dulgergil, and I.S. Sonmez, Prevalence of dental anxiety in 7- to 11-year-old children and its relationship to dental caries. Med Princ Pract, 2009. 18(6): p. 453-7.

12. Versloot, J., et al., Children's coping with pain during dental care. Community Dent Oral Epidemiol, 2004. 32(6): p. 456-61.

13. Townend, E., G. Dimigen, and D. Fung, A clinical study of child dental anxiety. Behav Res Ther, 2000. 38(1): p. 31-46.

14. Moore, R. and I. Brodsgaard, Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dentistry and Oral Epidemiology, 2001. 29: p. 73-80.

15. Folayan, M.O., et al., The effect of psychological management on dental anxiety in children. J Clin Pediatr Dent, 2003. 27(4): p. 365-70.

16. Harris, R.V., et al., Unravelling Referral Paths Relating to the Dental Care of Children: A Study in Liverpool. Primary Dental Care, 2008. 15: p. 45-52.

17. Evans, D., et al., A review of rerral patterns to paediatric dental consulant clinics. Community Dental Health, 1991. 8: p. 357-360.

18. Shaw, A.J., J.H. Nunn, and R.R. Welbury, A survey of referral patterns to a paediatric dentistry unit over a 2-year period. International Journal of Paediatric Dentistry, 1994. 4: p. 233-237.

19. Kendell, P.C., Childhood coping: Avoiding a lifetime of anxiety. Behaviour Change, 1992. 9: p. 1-8.

20. Salloum, A., et al., Overcoming Barriers to Using Empirically Supported Therapies to Treat Childhood Anxiety Disorders in Social Work Practice. Child Adolesc Soc Work J, 2009. 26(259-273).

21. Keller, M., et al., Chronic course of anxiety disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry, 1992. 31: p. 595-599.

22. Folayan, M.O. and E. Idehen, Factors influencing the use of behavioral management techniques during child management by dentists. J Clin Pediatr Dent, 2004. 28(2): p. 155-61.

20

23. Williams, C. and A. Garland, A cognitive-behavioural therapy assessment model for use in everyday clinical practice. Adv Psychiatr Treat, 2002. 8: p. 172-179.

24. Koroluk, L.D., Dental anxiety in adolescents with a history of childhood dental sedation. ASDC J Dent Child, 2000. 67(3): p. 200-5, 161.

25. Buchanan, H. and N. Niven, Further evidence for the validity of the Facial Image Scale. International Journal of Paediatric Dentistry, 2003. 13: p. 368-369.

26. Barros, L. and H. Buchanan, Correspondence between dentist and child ratings of dental anxiety in Portugal: A preliminary study. Rev Port Estomatol Med Dent Cir Maxilofac (Portuguese Journal of Oral and Maxillofacial Surgery), 2011. 52: p. 13-15.

27. Bankole, O.O., et al., Maternal and child's anxiety--effect on child's behaviour at dental appointments and treatments. Afr J Med Med Sci, 2002. 31(4): p. 349-52.

28. Gustafsson, A., et al., Dental behaviour management problems: the role of child personal characteristics. Int J Paediatr Dent, 2010. 20(4): p. 242-53.

29. Aartman, I., et al., Appraisal of behavioral measurement techniques for assessing dental anxiety and fear in children: A review. Psychopathology and Behavioural Assessment, 1996. 18: p. 153-171.

30. Eiser, C. and S. Twamley, eds. Talking to children about health and illness. In Qualitative Health Psychology, ed. M. Murray and K. Chamberlain. 1999, Sage: London.

31. Luoto, A., et al., Can parents and children evaluate each other's dental fear? Eur J Oral Sci, 2010. 118(3): p. 254-8.

32. Gustafsson, A., et al., Child dental fear as measured with the Dental Subscale of the Children’s Fear Survey Schedule: the impact of referral status and type of informant (child versus parent). Community Dent Oral Epidemiol, 2010. 38(3): p. 256-266.

33. Carson, P. and R. Freeman, Dental caries, age and anxiety: factors influencing sedation choice for children attending for emergency dental care. Community Dent Oral Epidemiol, 2001. 29: p. 30-36.

34. Rebok, G., et al., Elementary School-Aged Children's Reports of Their Health: A Cognitive Interviewing Study. Quality of Life Research, 2001. 10: p. 59-70.

35. Ross, D.J. and S.A. Ross, Childhood Pain: the school aged child's viewpoint. Pain, 1984. 20: p. 179-191.

36. Harbeck, C. and L. Peterson, Elephants Dancing in My Head: A Developmental Approach to Children's Concepts of Specific Pains. Child Development, 1992. 62: p. 138-149.

37. Woolley, M.E., G.L. Bowen, and N.K. Bowen, Cognitive Pretesting and the Developmental Validity of Child Self-Report Instruments: Theory and Applications. Res Soc Work Pract, 2004. 14: p. 191-200.

38. Newton, J.T. and D.J. Buck, Anxiety and Pain Measures in Dentistry: A guide to their quality and application. JADA, 2000. 131: p. 1449-1457.

39. Schuurs, A. and J. Hoogstraten, Appraisal of dental anxiety and fear questionnaires: a review. Community Dentistry and Oral Epidemiology, 1993. 21: p. 329-339.

40. Aartman, I.H., et al., Self-report measures of dental anxiety and fear in children: a critical assessment. ASDC Journal of Dentistry for Children, 1998. 65: p. 252-258.

41. Klinberg, G., Dental anxety and behaviour management problems in paediatric dentistry - a review of background factors and diagnostics. Eur Arch Paediatr Dent, 2008. 9: p. 11-15.

42. Newton, J.T. and D.J. Buck, Anxiety and pain measures in dentistry: A guide to their quality and application. Journal of the American Dental Association, 2000. 131(10): p. 1449-1457.

43. Cuthbert, M.I. and B.G. Melamed, A screening device: Children at risk for dental fear and management problems. J Dent Child (Chic), 1982. 49: p. 432-6.

44. Scherer, M.W. and C.Y. Nakamura, A fear survey schedule for children (FSS-FC): a factor analytic comparison with manifest anxiety (CMAS). Beh Res Ther, 1968. 6: p. 173-182.

45. Carson, P. and R. Freeman, Characteristics of children attending for dental general anaesthesia in 1993 and 1997. Prim Dent Care, 2000. 7(4): p. 163-7.

46. Carson, P. and R. Freeman, Assessing child dental anxiety: the validity of clinical observations. Int J Paediatr Dent, 1997. 7: p. 171-176.

47. Corah, N.L., Development of a dental anxiety scale. J Dent Res, 1969. 48: p. 596.

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48. Buchanan, H. and N. Niven, Validation of a Facial Image Scale to assess child dental anxiety. Int J Paediatr Dent, 2002. 12(1): p. 47-52.

49. Wong, H.M., G.M. Humphris, and G.T.R. Lee, Preliminary validation and reliability of the modified child dental anxiety scale. Psychol Rep, 1998. 83: p. 1179-1186.

50. Howard, K.E. and R. Freeman, Reliability and validity of a faces version of the Modified Child Dental Anxiety Scale. Int J Paediatr Dent, 2007. 17(4): p. 281-8.

51. Olumide, F., et al., Anticipatory anxiety in children visiting the dentist: lack of effect of preparatory information. Int J Paediatr Dent, 2009. 19(5): p. 338-342.

52. Pickrell, J.E., et al., Using memory restructuring strategy to enhance dental behaviour. Int J Paediatr Dent, 2007. 17(6): p. 439-448.

53. Kuscu, O.O. and S. Akyuz, Children's preferences concerning the physical appearance of dental injectors. J Dent Child (Chic), 2006. 73(2): p. 116-21.

54. Howard, K.E. and R. Freeman, An evaluation of the PALS after treatment modelling intervention to reduce dental anxiety in child dental patients. Int J Paediatr Dent, 2009. 19(4): p. 233-42.

55. Hosey, M.T., et al., Summary of: The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction. Br Dent J, 2009. 207(1): p. 32-33.

56. Venham, L.L. and E. Gaulin-Kremer, A self-report measure of situational anxiety for young children. Pediatr Dent, 1979. 1: p. 91-96.

57. Kleinknecht, R.A., et al., Factor analysis of the dental fear survey with cross-validation. J Am Dent Assoc, 1984. 108: p. 59-61.

58. Taani, D.Q., Dental attendance and anxiety among public and private school children in Jordan. Int Dent J, 2002. 52(1): p. 25-9.

59. Kleinknecht, R., R. Klepac, and L. Alexander, Origins and characterisics of fear of dentistry. JADA, 1973. 86: p. 842-848.

60. Buchanan, H., Development of a computerised dental anxiety scale for children: validation and reliability. Br Dent J, 2005. 199(6): p. 359-62; discussion 351; quiz 372.

61. Buchanan, H., Assessing dental anxiety in children: the Revised Smiley Faces Program. Child Care Hlth Dev, 2010. 36(4): p. 534-538.

62. Humphris, G.M., T. Morrisson, and S. Lindsay, The modified dental anxiety scale: validation and United Kingdom norms. Community Dent Health, 1995. 12: p. 143-150.

63. Stouthard, M.E.A., Angst voor de tandheelkundige behandeling. Ontwikkeling en validatie van een vragenlijst voor onderzoek en praktijk [PhD thesis}. Amsterdam: De Kreeft. 1989.

64. Alexopoulos, E., et al., A report on dental anxiety levels in children undergoing nitrous oxide inhalation sedation and propofol target controlled infusion intravenous sedation. Eur Arch Paediatr Dent, 2007. 8(2): p. 82-6.

65. Holmes, R.D. and N.M. Girdler, A study to assess the validity of clinical judgement in determining paediatric dental anxiety and related outcomes of management. Int J Paediatr Dent, 2005. 15(3): p. 169-76.

66. Folayan, M.O. and A. Fatusi, Effect of psychological management techniques on specific item score change during the management of dental fear in children. J Clin Pediatr Dent, 2005. 29(4): p. 335-40.

67. ten Berge, M., Dental fear in children: clinical consequences. Suggested behaviour management strategies in treating children with dental fear. European Archives of Paediatric Dentistry, 2008. 9: p. 41-46.

68. Titman, P., M. Smith, and P. Graham, Assessment of quality of life in children and adolescents. Clinical Child Psychology and Psychiatry, 1997. 2: p. 597-606.

69. Ericsson, K.A. and H.A. Simon, Verbal reports as data. Psychological Review, 1980. 87: p. 215-250.

70. Hallberg, U. and G. Klinberg, Giving low priority to oral healthcare. Voices from people with disabilities in a grounded theory study. Acta Odonto Scand, 2007. 65: p. 265-270.

71. Nakai, Y., et al., The Children's Fear Survey Schedule-Dental Subscale in Japan. Community Dentistry and Oral Epidemiology, 2005. 33(3): p. 196-204.

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72. Wogelius, P., et al., Dental anxiety among survivors of childhood cancer: a cross-sectional study. Int J Paediatr Dent, 2009. 19(2): p. 121-6.

73. Yamada, M.K., et al., Cooperation during dental treatment: the Children's Fear Survey Schedule in Japanese children. Int J Paediatr Dent, 2002. 12(6): p. 404-9.

74. Ilieva, E., et al., A study on fear provoking factors in students from the town of Plovdiv. Folia Med (Plovdiv), 2001. 43(1-2): p. 16-9.

75. Majstorovic, M., J.S. Veerkamp, and I. Skrinjaric, Reliability and validity of measures used in assessing dental anxiety in 5- to 15-year-old Croatian children. Eur J Paediatr Dent, 2003. 4(4): p. 197-202.

76. Majstorovic, M. and J.S. Veerkamp, Developmental changes in dental anxiety in a normative population of Dutch children. Eur J Paediatr Dent, 2005. 6(1): p. 30-4.

77. Van Meurs, P., et al., Child coping strategies, dental anxiety and dental treatment: the influence of age, gender and childhood caries prevalence. Eur J Paediatr Dent, 2005. 6(4): p. 173-8.

78. Folayan, M.O. and E.E. Idehen, Effect of information on dental anxiety and behaviour ratings in children. Eur J Paediatr Dent, 2004. 5(3): p. 147-50.

79. Luoto, A., et al., Oral-health-related quality of life among children with and without dental fear. Int J Paediatr Dent, 2009. 19(2): p. 115-20.

80. Majstorovic, M., et al., Dental anxiety in relation to emotional and behavioral problems in Croatian adolescents. Coll Antropol, 2007. 31(2): p. 573-8.

81. Carson, P. and R. Freeman, Dental caries, age and anxiety: factors influencing sedation choice for children attending for emergency dental care. Community Dent Oral Epidemiol, 2001. 29(1): p. 30-6.

82. Klaassen, M., J. Veerkamp, and J. Hoogstraten, Predicting dental anxiety. The clinical value of anxiety questionnaires: an explorative study. Eur J Paediatr Dent, 2003. 4(4): p. 171-6.

83. Arapostathis, K.N., et al., Reliability and validity of the Greek version of the Children's Fear Survey Schedule-Dental Subscale. Int J Paediatr Dent, 2008. 18(5): p. 374-9.

84. Kuscu, O.O., et al., Short communication: preferences of dentist's attire in a group of Istanbul school children related with dental anxiety. Eur Arch Paediatr Dent, 2009. 10(1): p. 38-41.

85. Gustafsson, A., et al., Child dental fear as measured with the Dental Subscale of the Children's Fear Survey Schedule: the impact of referral status and type of informant (child versus parent). Community Dent Oral Epidemiol, 2010. 38(3): p. 256-266.

86. Gustafsson, A., et al., Possible predictors of discontinuation of specialized dental treatment among children and adolescents with dental behaviour management problems. European Journal of Oral Sciences, 2010. 118(3): p. 270-277.

87. Bakarcic, D., et al., Structural analysis of dental fear in children with and without dental trauma experience. Coll Antropol, 2007. 31(3): p. 675-81.

88. Peretz, B., Y. Nazarian, and E. Bimstein, Dental anxiety in a students' paediatric dental clinic: children, parents and students. Int J Paediatr Dent, 2004. 14(3): p. 192-8.

89. Gulen, F., et al., The efficacy of bronchodilatators on respiratory functions undergoing dental treatment in asthmatic children. Minerva Pediatr, 2007. 59(1): p. 29-34.

90. Fabian, G., et al., Attitude toward death: does it influence dental fear? Ann N Y Acad Sci, 2007. 1113: p. 339-49.

91. Krekmanova, L., et al., Everyday- and dental-pain experiences in healthy Swedish 8-19 year olds: an epidemiological study. Int J Paediatr Dent, 2009. 19(6): p. 438-47.

92. Hoge, C., et al., Physiologic signs during dental treatment in overweight vs normal weight children. Pediatr Dent, 2008. 30(6): p. 522-9.

93. Majstorovic, M., et al., Factors predicting a child's dental fear. Coll Antropol, 2001. 25(2): p. 493-500.

94. Hosey, M.T., et al., Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia. Br Dent J, 2006. 200(1): p. 39-43; discussion 27; quiz 50.

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95. Arch, L.M., G.M. Humphris, and G.T. Lee, Children choosing between general anaesthesia or inhalation sedation for dental extractions: the effect on dental anxiety. Int J Paediatr Dent, 2001. 11(1): p. 41-8.

96. Harman, K., et al., An investigation of language used by children to describe discomfort expected and experienced during dental treatment. Int J Paediatr Dent, 2005. 15(5): p. 319-26.

97. Folayan, M.O., E.E. Idehen, and O.O. Ojo, Identified factors in child-dentist relationship important for the management of dental anxiety in Nigerian children. Eur J Paediatr Dent, 2004. 5(4): p. 225-32.

98. Marsac, M.L. and J.B. Funk, Relationships among psychological functioning, dental anxiety, pain perception, and coping in children and adolescents. J Dent Child (Chic), 2008. 75(3): p. 243-51.

99. Folayan, M.O., E.E. Idehen, and D. Ufomata, The effect of sociodemographic factors on dental anxiety in children seen in a suburban Nigerian hospital. Int J Paediatr Dent, 2003. 13(1): p. 20-6.

100. Folayan, M.O., et al., Parental anxiety as a possible predisposing factor to child dental anxiety in patients seen in a suburban dental hospital in Nigeria. Int J Paediatr Dent, 2002. 12(4): p. 255-9.

101. Fox, C. and J.T. Newton, A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children. Community Dent Oral Epidemiol, 2006. 34(6): p. 455-9.

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Table 1. Advantages of conducting an assessment of children’s dental anxiety

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Patient level Service organisational level Epidemiology/Dental Public Health

Increase patient’s and dental teams’ understanding of the factors contributing to patient’s anxiety

Act as a communication aid between the patient and the dental team

Completed measure/assessment can be stored in patient’s notes as a way of information sharing within the dental team

Helps dental team differentiate anxiety from behavioural issues

Assessment can inform management approaches so that interventions directly target areas which are maintaining the child’s anxiety (e.g. unhelpful thoughts, specific triggers)

Assess appropriateness of dental referrals into a service (e.g. severity of dental anxiety)

Assess effectiveness of specific management approaches in reducing children’s dental anxiety (behavioural interventions, pharmacological methods)

Collect information on numbers of dentally anxious children referred into services

Collect information on numbers of dentally anxious children receiving specific management approaches with a service (e.g. sedation, general anaesthesia)

Investigate prevalence of dental anxiety in children and trends in prevalence over time

Examine risk factors and symptoms of dental anxiety

Evaluate the effectiveness of interventions to manage/reduce anxiety

Examine relationships between dental anxiety and oral health outcomes (e.g. clinical status, oral health related quality of life, treatment satisfaction)

Table 2. Description of dental anxiety measures which studies have employed to assess children’s dental anxiety

Measure Number of items & scoring

Development Means reported

Populations

Children’s Fear Survey Schedule Dental Subscale

No of items: 15 Scoring: 1=No fear to 5=Very frightened Range: 15-75Cut off: >32 anxious, >38/39 highly anxious

Designed for: ChildrenChild involvement: No

Clinical: 22.5-45.1Population: 22.9-36.7

Studies: 28 Age range: 3.5 to 19 yearsCountries: Bulgaria, Croatia, Denmark, Finland, Greece, Japan, Netherlands, Sweden, Turkey, UK and USA

Dental Anxiety Scale & Modified Dental Anxiety Scale *

No of items: 4 or 5* Scoring: Variety of response statements to choose from & 1=Not anxious to 5=Extremely anxious* Range: 4-20 & 5-25*Cut off: 9-12 moderate anxiety, 13-14 high anxiety, 15-20 severe anxiety (phobia)

Original measure: AdultChild involvement: No

Clinical: 7.1-9.5 & 10.8-13.5*Population: 9.0-11.6

Studies: 14 Age range: 5 to 19 yearsCountries: Canada, Croatia, Hungary, Israel, New Zealand, Sweden, Turkey, UK and USA

Modified Child Dental Anxiety Scale

No of items: 8Scoring: Relaxed=1 to 5=very worried Range: 8 -40Cut off: >26 anxious

Original measure: ChildChild involvement: Yes, to some extent

Clinical: 16.1-26.2Population: 18.2-19.9

Studies: 10 Age range: 4 to 17 yearsCountries: UK

Dental Fear Schedule Subscale Short Form

No of items: 8 Scoring: 1=No fear to 5=Very frightened Range: 8-40Cut off: >20 anxious

Designed for: ChildrenChild involvement: No

Clinical: 12.6-16.5

Studies: 7 Age range: 8 to 15 yearsCountries: Nigeria and USA

Facial Image Scale No of items: 1 Scoring: 5 faces: 1=most positive face to 5=most negative faceRange: 1-5Cut off: N/I

Designed for: ChildrenChild involvement: No

Clinical: 1.6-2.5

Population: 2.3-3.0

Studies: 7 Age range: 3 to 18 yearsCountries: Turkey and UK

Venham Picture Scale

No of items: 8 pictures (each contains an anxious & non-anxious boy)Scoring: Anxious boy =1 or non-anxious boy =0.Range: 0-8Cut off: N/I

Designed for: ChildrenChild involvement: Yes, to some extent

Clinical: 1.1-2.5Population: N/I

Studies: 4 Age range: 3 to 18 yearsCountries: Turkey and UK

Dental Fear Survey & Modified DFS*

No of items: 20 or 15* Scoring: 1=No fear or reaction to 4=great fear or reaction Range: 15-60 or 20-80*Cut off: N/I

Original measure: AdultChild involvement: No

Clinical: N/I Population: 40.6*

Studies: 4 Age range: 8 to 18 yearsCountries: Hungary, Israel and Jordan

Smiley Faces Programmes & Revised SFP *

No of items: 4 or 5* Scoring: 7 faces:1=most positive face 5=most negative face Range: 4-28 & 5-35*Cut off: N/I

Original measure: ChildChild involvement: Yes, to some extent

Population: 18.0 & 21.9*

Studies: 2 Age range: 4 to 15 yearsCountries: UK

Dental Anxiety Inventory – Short Version

No of items: 9 Scoring: 1=complete disagreement to 5=complete agreement Range: 9-45Cut off: >33 high anxiety

Original measure: AdultChild involvement: No

Clinical: N/I Studies: 1 Age range: 5 to 12 yearsCountries: Croatia

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N/I: No information available - based on the examination of information included within the studies reviewed

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Table 3. Evaluation of dental anxiety measures which studies have employed to assess children’s dental anxiety

Measure Reliability & Validity Areas assessedChildren’s Fear Survey Schedule Dental Subscale

Cronbach’s alpha: 0.8-0.9Test-retest: 0.9 Concurrent validity: N/I

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

Dental Anxiety Scale & Modified Dental Anxiety Scale *

Cronbach’s alpha: 0.8Test-retest: 0.7Concurrent validity: N/I

Physical symptoms: Yes Behaviours: No Thoughts: YesFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

Modified Child Dental Anxiety Scale

Cronbach’s alpha: 0.8Test-retest: 0.5-1.0Concurrent validity: significantly correlated with CFSS-DS (r=0.8), SFP-R (r=0.6) & DAS (r=0.7)

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

Dental Fear Schedule Subscale Short Form

Cronbach’s alpha: N/ITest-retest: N/IConcurrent validity: significantly correlated with clinical observations (k=0.7-0.9)

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – trait dental anxietyLife situation: Yes - triggers of anxiety

Facial Image Scale Cronbach’s alpha: N/A - 1 item Test-retest: N/IConcurrent validity: significantly correlated with VPS (r=0.7)

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – state moodLife situation: Yes – triggers of anxiety

Venham Picture Scale Kuder-Richardson: 0.8Test-retest: 0.7Concurrent validity: N/I

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – state emotions (including dental anxiety)Life situation: Yes - triggers of anxiety

Dental Fear Survey and Modified DFS

Cronbach’s alpha: 0.9Test -retest: N/IConcurrent validity: significantly correlated with DAS (r=.8)

Physical symptoms: Yes Behaviours: YesThoughts: NoFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

Smiley Faces Programmes & Revised SFP *

Cronbach’s alpha: 0.7-0.8Test-retest: 0.8Concurrent validity: significantly correlated with CFSS-DS (r=0.6) & MCDAS (r=0.6)

Physical symptoms: No Behaviours: No Thoughts: NoFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

Dental Anxiety Inventory – Short Version

Cronbach’s alpha: N/ITest-retest: N/IConcurrent validity: N/I

Physical symptoms: Yes Behaviours: Yes Thoughts: YesFeelings: Yes – trait dental anxietyLife situation: Yes – triggers of anxiety

N/I: No information available - based on the examination of information included within the studies reviewed

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