Psychological Assessment © 2010 American Psychological Association

2010, Vol. 22, No. 2, 279 –287 1040-3590/10/$12.00 DOI: 10.1037/a0018678

Development and Psychometric Evaluation of the Index of Dental

Anxiety and Fear (IDAF-4C⫹)
Jason M. Armfield
University of Adelaide

The measurement of dental fear is important due to its high prevalence and appreciable individual,
clinical, and public health consequences. However, existing measures of dental anxiety and fear (DAF)
have theoretical or practical limitations. This study describes the development and subsequent assessment
of the reliability and validity of test scores of a new DAF scale for adults. The Index of Dental Anxiety
and Fear (IDAF-4C⫹) contains 3 modules that measure DAF, dental phobia, and feared dental stimuli.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

The final 8-item DAF module (IDAF-4C) assesses emotional, behavioral, physiological, and cognitive
components of the anxiety and fear response. The proposed scale dimensionality received support from
exploratory factor analysis. IDAF-4C items showed good internal consistency (Cronbach’s ␣ ⫽ .94) and
test–retest reliability at 4 months (r ⫽ .82), and the scale was strongly associated with other dental fear
scales as well as with dental visiting patterns, avoidance of the dentist, and dental phobia diagnosis. The
convergent and predictive validity of the IDAF-4C compared positively to Corah’s (1969; Corah, Gale,
& Illig, 1978) Dental Anxiety Scale and a single-item measure of dental fear, and the scale predicted
future dental visiting and visit perceptions. Both phobia and stimulus modules showed strong and
statistically significant associations with DAF ratings. In all, sufficient evidence is provided to demon-
strate that the new scale would be a useful tool to assess DAF in an adult population. The IDAF-4C⫹ is
based on strong theoretical underpinnings, yet the scale is practical enough for application across a
variety of potential uses.

Keywords: dental fear, phobia, scale development, assessment, dental visiting

Dental anxiety and fear act as a barrier to receiving dental care
by reducing initial treatment seeking and causing missed or de-
layed appointments even after treatment has been sought (Kling-
berg, 1995; Milgrom & Weinstein, 1993). This is of serious
concern because lack of treatment is likely to lead, in many cases,
to a continued worsening of oral health problems (Armfield, Slade,
& Spencer, 2009; Schuller, Willumsen, & Holst, 2003). When
unendurable pain eventually drives dentally fearful individuals to
receive care, their oral health may be compromised, their problems
may be severe, and significant and sometimes painful or uncom-
fortable treatment may be required. A vicious cycle may be estab-
lished where the invasive treatment required for a problem that has
deteriorated over time leads to a reinforcement of fear, further
avoidance of dental treatment, and continued future disease expe-
rience (Armfield, Stewart, & Spencer, 2007).
Because of the considerable implications of dental fear at the
individual, practitioner, and public health levels, it is important to
Jason M. Armfield, Australian Research Centre for Population Oral
Health, School of Dentistry, University of Adelaide, Adelaide, South
Australia, Australia.
Jason M. Armfield is now at the Department of Dental Public Health
Sciences, University of Washington.
This study was supported by a grant from the Australian Dental Re-
search Foundation.
Correspondence concerning this article should be addressed to Jason M.
Armfield, Australian Research Centre for Population Oral Heath, University
of Adelaide, South Australia, 5005, Australia. E-mail: jason.armfield@
adelaide.edu.au
be able to determine who has dental anxiety and fear, how many
people are affected, and the nature and extent of their concerns. To
this end, a number of scales and measures have been developed
over several decades (for reviews, see, Armfield, in press; Newton
& Buck, 2000; Schuurs & Hoogstraten, 1993). These scales have
provided a basis for an appreciably expanded understanding of
dental anxiety and fear. However, the sheer number of scales and
the continued development of new or revised versions reveal a
level of dissatisfaction with previous attempts to measure dental
anxiety and fear. Several of the most widely used scales have been
criticized for being both psychometrically insufficient (Schuurs &
Hoogstraten, 1993) and theoretically lacking (Armfield, in press;
Yuan, Freeman, Lahti, Lloyd-Williams, & Humphris, 2008). The
frequent failure to adequately articulate an underlying theory is of
serious concern, as without this “nomological net” (Cronbach &
Meehl, 1955, p. 290) the construct validity of a scale may be
regarded as seriously compromised (Clark & Watson, 1995).
The measurement of dental anxiety and fear has tended to reflect
one of two approaches. The first involves the measurement of a
person’s emotional content in relation to his or her concerns, with
items tapping how a person feels about going to the dentist. The
second approach is to assess people’s predicted reactions to a
series of specific stimuli, events, or encounters. The overall mean
or summed score of expected reactions to a list of specific stimuli
is assumed to provide a proxy measure of fear itself. Occasionally,
these two approaches are combined in a single scale to a greater or
lesser extent.
One of the most serious concerns with the current approaches to
measuring fear is that they seldom take into account the multidi-

279
 280 ARMFIELD

mensional nature of anxiety and fear. It has been widely recog-
nized that the emotion of fear contains several components that,
although for the most part (but not always) coinciding as part of an
anxiety or fear response set, are nonetheless conceptually discrete
(Edelmann, 1992; Lang, 1971; Schwarzer, van der Ploeg, & Spiel-
berger, 1987; Stouthard, Mellenbergh, & Hoogstraten, 1993). Spe-
cifically, it can be argued that anxiety and fear responses contain
cognitive, emotional, behavioral, and physiological components
(Armfield, in press; Stouthard et al., 1993; Westermeyer, 2005).
Each of these components contributes something substantial to the
overall anxiety or fear response, and each has its basis in the
biological fight or flight response to threatening stimuli. It is
proposed that to accurately and appropriately measure dental anx-
iety and fear, each of these components must be assessed. Failure
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
in Education, 1999). The newly developed dental fear measure was
therefore tested using a number of types of validity evidence as
well as various assessments of scale-score reliability. It was hy-
pothesized that validity would be demonstrated by evidence de-
rived from factor analysis, significant correlations with other mea-
sures of dental fear, associations with visiting frequency,
avoidance of the dentist due to dental fear and fear of specific
dental stimuli, and the ability of the scale scores to predict subse-
quent dental visiting and whether the visit was regarded as a
negative or positive experience. Reliability of the test scores was
assessed by measures of internal consistency, inter-item correla-
tions, and test–retest reliability. It was also predicted that the
dental anxiety and fear module would demonstrate stronger asso-
ciations with dental visiting patterns, self-rated oral health, and

to measure important facets or dimensions of a construct, termed phobia diagnosis than would other dental fear measures.
construct underrepresentation, seriously threatens the construct
validity of scale scores (Messick, 1994). Materials and Method
A further, albeit frequently unrecognized element of any anxiety
or fear is the social component. Indeed, when a fear takes on a Sample and Study Procedure
meaningful social consequence, the fear can be said to enter the
The research was carried out during 2008 and comprised a
realm of a diagnosable psychiatric condition. In the Diagnostic and
nested questionnaire study of a random sample of Australian adults
Statistical Manual of Mental Disorders (4th ed. [DSM–IV]), a
participating in the National Dental Telephone Interview Survey
specific phobia is explicitly defined as a marked fear that causes
(NDTIS) conducted by the Australian Research Centre for Popu-
significant impairment to a person’s normal routine, occupational
lation Oral Health (Carter & Stewart, 2003; Slade, Spencer, &
or academic functioning, or social activities and relationships
Roberts-Thomson, 2007) at the University of Adelaide (Adelaide,
(American Psychiatric Association, 1994). While some dental fear
Australia). The NDTIS is a periodic (every 2 or 3 years) national
scales have used cutpoints to define extreme or phobic fear, such
study that uses a computer-assisted telephone interview (CATI)
an approach is at odds with the established clinical definition of
and is funded by the Australian government Department of Health
phobia. To provide an indication of whether or not a dental fear
and Ageing. The survey addresses a range of dental health as well
might be classifiable as a dental phobia, a self-report scale would
as reported needs and access issues. The NDTIS uses a primary
need to incorporate elements of the diagnostic criteria into the
approach letter and up to six call attempts of a random sample of
determination in addition to the capacity for exclusion of the
the entire Australian population. Stratified sampling from the
disorder due to a differential diagnosis. To date, no measure of
Australian electoral roll was used, with strata defined by capital
dental anxiety or fear has attempted this approach.
city and rest of state for each of Australia’s eight states and
The aim of this study was to develop a self-report measure of
territories (with the exception of the Australian Capital Territory,
dental anxiety and fear that assesses the four elements of the
which, due to its smaller size, comprised a single stratum). In all,
anxiety and fear response set—the cognitive, behavioral, emo-
13 strata were defined.
tional, and physiological components. From the outset, the mea-
At the end of the NDTIS CATI, participants were asked whether
sure was intended to assume a modular approach, with additional
they would be interested in participating in an additional (un-
add-on modules designed to assess dental phobia and specific
named) questionnaire study. A randomly selected 25% of inter-
feared stimuli. It is appreciated that the needs of dental clinicians
ested participants were approached to participate in what was
may vary from the needs of epidemiologists, behavioral research-
called the National Dental Anxiety and Fear Survey. With an
ers, psychologists, or psychiatrists in terms of what is desired or
estimated sample size for the NDTIS of approximately 5,850
useful when assessing dental fear. The phobia and stimulus mod-
people, it was expected that approximately 1,500 people would be
ules were therefore developed and incorporated into the measure to
approached to participate in the current dental fear study.
enable the collection of additional information that, while poten-
Participants were sent a questionnaire and, if necessary, a re-
tially useful, is not central to the quantitative assessment of a
minder card and then a replacement questionnaire. Approximately
person’s dental anxiety and fear per se.
4 months later, a random sample of 600 participants who had
This study reports on both the development and psychometric
provided a completed questionnaire were sent a second question-
evaluation of the new dental fear measure, termed the Index of
naire to enable a test–retest of the dental anxiety and fear scale.
Dental Anxiety and Fear (IDAF-4C⫹). While there is near univer-
Individuals selected for the retest questionnaire received a primary
sal agreement that any good scale must be both valid and reliable,
approach letter approximately one week before receiving the ques-
the classification and definition of types of validity have varied
tionnaire and were again sent a single reminder card and replace-
considerably from one proponent to the next, and the traditional
ment questionnaire if necessary.
taxonomy of content, criterion, and construct validity (Cronbach &
Meehl, 1955) has more recently given way to the idea of validity
Measures
as a unitary concept that can be assessed by several sources of
evidence (American Educational Research Association, American Dental Anxiety Scale. Despite significant problems (Arm-
Psychological Association, & National Council on Measurement field, in press; Humphris, Morrison, & Lindsay, 1995), the Dental
 DEVELOPMENT OF A DENTAL FEAR SCALE
Anxiety Scale (DAS) developed by Corah (1969; Corah, Gale, &
Illig, 1978) has been and remains the most widely used measure of
dental fear reported in the literature. The scale includes four
questions that assess anxiety about anticipated or imagined dental
treatment procedures. It has been translated into several languages,
has published norms, and has been found to be both reasonably
valid and reliable (Schuurs & Hoogstraten, 1993).
Index of Dental Anxiety and Fear. The IDAF-4C⫹ (which
identifies the core module, the specifier 4C being for the four
components— emotional, behavioral, physiological, and cogni-
tive— covered by the measure, and the added modules indicated by
the ⫹) comprised the core fear module (IDAF-4C) as well as the
phobia (IDAF-P) and stimulus (IDAF-S) modules.
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An initial battery of 29 items was developed for the core module
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covering the four fear response components and some identified
subareas within the components. Items were generated by the
author based on published theoretical discussions of the various
components of anxiety and fear as well as being derived from other
sources such as existing anxiety or fear scales and published
self-reports of dentally anxious individuals. Subareas related to
catastrophizing and preoccupation were identified within the cog-
nitive component, avoidance and escape were identified as subar-
eas within the behavioral component, and subareas of the physio-
logical component were identified as specific physiological
responses as well as disgust/vasovagal responses. After discussion
of the items by a small group of invited experts, the list of items
was reduced to a total of 16 items to be included in the baseline
questionnaire. Items were selected so as to provide four items
relating to each of the four identified anxiety and fear components,
with elimination of items driven by an assessment of item rele-
vance, clarity of wording, possible duplication, and the overall
breadth of coverage for each component. The presentation of items
from each component in the list was randomized within each of
four blocks of four items. Participants were asked how much they
agreed with each statement, with possible responses on a 5-point
Likert-type scale ranging from disagree (1) to strongly agree (5).
The phobia module comprised five items and was explicitly
based on DSM–IV diagnostic criteria for specific phobia (Ameri-
can Psychiatric Association, 1994). Three items related to diag-
nostic specifiers, while two items were concerned with differential
diagnosis. Participants were asked whether the statements applied
to them, with the possible response being either “yes” or “no.”
Given that the core module assessed levels of anxiety and fear, the
phobia module focused on functional impairment, distress about
the level of dental fear, and the belief that the fear was excessive
or unreasonable. Wording of items closely reflected the wording
used in the DSM–IV. Differential diagnosis was provided for both
social phobia and panic disorder (with or without agoraphobia) as
both these conditions may produce fear and avoidance of going to
the dentist without indicating dental phobia per se. The phobia
module was designed to provide a nonclinical diagnosis of any
phobia or disorder with a dental component (P-DENT) as well
as for a strict DSM–IV diagnosis of specific (dental) phobia
(P-DSMS). In addition, because many dental fears may be based in
objectively traumatic, painful, or aversive experiences, a less strict
DSM–IV phobia diagnosis was also possible whereby people were
not required to state a conviction that their fear was either exces-
sive or unreasonable (P-DSMR). A mean score of 3 or higher on the
281
core fear module (IDAF-4C) was taken as meeting the diagnostic
criteria for a marked fear required by DSM–IV.
The stimulus module comprised 10 items covering significant
overlapping content found in several existing scales. All items
were also cross-validated against reported concerns found on on-
line dental phobia support forums and through discussions with
dentists. Items were related to pain, embarrassment, lack of con-
trol, numbness, feeling sick, treatment cost, needles, gagging, not
knowing what was happening, and having an unsympathetic den-
tist. Participants were asked to what extent they were anxious
about each of the stimuli when they went to the dentist, with
possible responses on a 5-point unidimensional adjectival scale
ranging from not at all (1) to very much (5).
Dental avoidance. Participants were asked whether they
avoided visiting the dentist as often as they felt they needed to. If
they responded “yes,” they were asked to indicate the reasons why.
Available reasons were “lack of time/busy,” “cost/too expensive,”
“do not like dentists,” “inconvenient to get to,” “fear or anxiety,”
“just don’t get around to it,” and “other reason,” with possible
responses being “yes” or “no.”
Other data items from the NDTIS. Several other variables
were available as part of the data collected for the NDTIS. These
included a single-item dental fear (SIDF) measure that asked about
the amount of fear or distress that would be felt if the person were
to go to a dentist now, self-rated oral health, and dental visiting
characteristics including time since last visit, usual visiting fre-
quency, and usual reason for visiting the dentist.
Data items at follow-up. Participants were asked whether,
since filling out the initial baseline questionnaire 4 months previ-
ously, they had visited a dentist or dental professional, with mul-
tiple possible responses being “yes, private dentist,” “yes, public
dentist,” “yes, other,” and “no.” Those participants who responded
that they had been to a dentist were asked how they would describe
their recent dental visit(s), with possible responses indicated on
6-point Likert-type scale from extremely positive (1) to extremely
negative (6).
Statistical Analyses and Scale Assessment
All data in this study were weighted to the Age ⫻ Sex estimated
resident population (ERP) within each of the 13 strata employed in
the NDTIS. ERPs were obtained from population estimates pro-
vided online by the Australian Bureau of Statistics (2009) and
based on results from Australia’s 5-yearly national Census of
Population and Housing.
Because the phobia and stimulus modules were designed to be
used not as scales but for epidemiological and clinical purposes,
respectively, the majority of analyses presented in this article relate
to the development and psychometric testing of the core anxiety
and fear module. Unless stated otherwise, all analyses used SPSS
Version 17.
Items for the core anxiety and fear module (IDAF-4C) were
selected by the elimination of items with either very low or very
high responding (either 80% endorsement, as recommended by
Streiner & Norman, 1985), an assessment of item intercorrelations
and measures of internal consistency, and the use of exploratory
factor analysis (EFA) employing principal axis extraction with
promax rotation (␬ ⫽ 4) with Kaiser normalization. Both free and
forced four-factor solutions were tested.
 282 ARMFIELD

The internal consistency of the selected items for the IDAF-4C
was determined using Cronbach’s alpha and the intraclass corre-
lation coefficient. Pearson r correlation coefficients were com-
puted for items within each subscale, and subscale associations
were assessed using both Pearson r correlations and the kappa
statistic with off-diagonal quadratic weighting applied.
Pearson r correlation coefficients were computed between the
IDAF-4C and its components and the DAS and SIDF scores.
Univariate general linear modeling was also used to compare
scores on the IDAF-4C and DAS across phobia diagnosis catego-
ries and Pearson r correlations to examine the association between
fear of specific stimuli and scores on the IDAF-4C and DAS.
The IDAF-4C was compared to the DAS and SIDF measure for
predicting fear of specific dental stimuli, avoiding the dentist due
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naires marked “return-to-sender,” leaving a total of 1,083 respon-
dents (response rate ⫽ 72.0%). Of the 600 participants from
baseline approached to take part in the test–retest study, there were
485 respondents (response rate ⫽ 80.8%).
Prior to weighting, there was a statistically significant overrep-
resentation of females and older adults. However, weighting the
data to population age and sex characteristics removed the effects
of this participation bias and resulted in a representative sample of
the Australian population with a good representation of diverse
socioeconomic and demographic characteristics.
Dental Anxiety and Fear Module
Scale formation. Mean item scores, the percentage of the

to fear, decreased visiting frequency, poorer self-rated oral health,
and delayed dental visiting, using analysis of variance with fear as
the dependent variable, and measures of association tested using
eta squared.
Predictive validity for the IDAF-4C compared to the DAS was
assessed by comparing the dental fear scores and rated experience
of people who had visited and those who had not visited the dentist
at 4 months postbaseline. In addition, the test–retest reliability of
the IDAF-4C⫹ modules at 4-month follow-up was assessed by
correlating items and scale results.
Results
Participants
Of those people completing the NDTIS and agreeing to partic-
ipate in an additional questionnaire study, 1,511 were randomly
selected to be approached for the national dental anxiety and fear
survey. In all, there were 421 nonrespondents and seven question-
sample not endorsing each item, Cronbach’s alpha for subscales if
item was deleted, corrected item-total correlations (CITCs), and
unrotated and rotated factor loadings are presented in Table 1 for
each of the 16 original core dental anxiety and fear module items.
Three of the four items with the highest means came from the
emotional component of the IDAF-4C. Only 3 of the 16 items had
less than a 20% endorsement (1 from the cognitive component and
2 from the physiological component), which is recommended as a
minimum for a useful scale item (Streiner & Norman, 1995).
Reliability analyses were conducted for each four-item set of
statements corresponding to each of the fear components. Cron-
bach’s alpha was .85 for the cognitive component, .85 for the
physiological component, .90 for the behavioral component, and
.94 for the emotional component. CITCs were reasonably high for
all items, although they were less than .70 for two items on the
physiological component. CITCs were very high for the items
forming the emotional component.
EFA with principal axis extraction of factors with eigenvalues
of greater than one revealed a single-factor solution (shown in

Table 1
Item Descriptives and Results From Reliability and Factor Analyses

Rotated loadings from four-factor

Reliabilityb solution

Item Mean Percentage disagree Alpha if deleted CITC Single-factor loading 1 2 3 4

IDAF C1 1.76 58.5 .82 .71 .83 .72 ⫺.04 .27 ⫺.05
IDAF C2a 1.28 83.6 .83 .69 .69 ⫺.07 .20 .77 ⫺.03
IDAF C3 1.50 72.5 .81 .70 .79 .00 .07 .21 .65
IDAF C4a 1.41 77.1 .80 .74 .72 .15 ⫺.08 .59 .21
IDAF P1a 1.97 50.2 .79 .77 .91 .54 .38 .02 .06
IDAF P2 1.31 81.7 .84 .64 .69 .10 ⫺.09 .58 .25
IDAF P3a 1.85 51.0 .77 .78 .85 .61 .04 ⫺.02 .29
IDAF P4 1.33 82.2 .83 .66 .69 .03 ⫺.10 .32 .59
IDAF B1a 1.95 58.1 .85 .83 .85 .26 .63 .05 .00
IDAF B2 1.62 70.3 .86 .80 .79 ⫺.08 .80 .12 .07
IDAF B3a 2.08 50.8 .88 .75 .74 .19 .72 ⫺.06 ⫺.04
IDAF B4 1.50 77.6 .88 .75 .69 ⫺.06 .32 .17 .55
IDAF E1a 2.16 37.1 .93 .85 .85 .89 .10 .03 ⫺.11
IDAF E2a 1.74 60.8 .93 .84 .89 .58 .15 .35 ⫺.09
IDAF E3 2.00 42.9 .92 .87 .89 .63 .16 ⫺.14 .31
IDAF E4 1.99 45.8 .91 .90 .91 .52 .38 ⫺.09 .18

Note. Bolded values represent highest factor loadings. CITC ⫽ corrected item-total correlation; IDAF ⫽ Index of Dental Fear and Anxiety; IDAF
C1–C4 ⫽ items reflecting the cognitive component of the IDAF; IDAF P1–P4 ⫽ items reflecting the physiological component of the IDAF; IDAF
B1–B4 ⫽ items reflecting the behavioral component of the IDAF; IDAF E1–E4 ⫽ items reflecting the emotional component of the IDAF.
a
Item selected for final eight-item scale. b Alpha if deleted calculated based on four items for each component.
 DEVELOPMENT OF A DENTAL FEAR SCALE 283

Table 1 as the unrotated factor loading) that accounted for 67.8% Table 3
of the variance. This indicates a strong relatedness between all the Pearson r Correlations Between the IDAF-4C and Its
items in the scale. However, to investigate the theoretical four- Components and the DAS and SIDF Measure
component structure of the scale items, a second EFA with a
forced four-factor extraction and promax rotation was carried out. Measure 1 2 3 4 5 6 7
Rotated pattern matrix factor loadings indicated that all items 1. IDAF — .79 .94 .91 .95 .84 .57
designed to assess the emotional component loaded onto Factor 1, 2. IDAF-C — .67 .61 .71 .60 .37
three of the four items assessing the cognitive component loaded 3. IDAF-P — .81 .89 .82 .56
onto Factor 2, and three of the four items assessing the behavioral 4. IDAF-B — .79 .74 .49
5. IDAF-E — .83 .59
component loaded onto Factor 3. However, items assessing the
6. DAS — .58
physiological component were spread across the factors, with two 7. SIDF —
loading onto Factor 1, one loading onto Factor 2, and one loading
onto Factor 4. Examination of Factor 4 revealed it to contain items Note. IDAF ⫽ Index of Dental Anxiety and Fear; IDAF-C ⫽ cognitive
indicating possible panic attack symptoms. component of the IDAF; IDAF-P ⫽ physiological component of the IDAF;
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

IDAF-B ⫽ behavioral component of the IDAF; IDAF-E ⫽ emotional

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On the basis of the results discussed above for the item response
distributions, reliability analyses, and factor analysis, eight items were
selected for use on the final scale, with two items representing each
component of the anxiety and fear response set. The correlations
between each item for the four components were .64 for the cognitive
items, .77 for the physiological items, .79 for the behavioral items, and
.78 for the emotional items. The Pearson r correlation and weighted
kappa for associations between the mean component scores are shown
in Table 2. For kappa calculations, the continuous scales were recoded
into four categories, 1–2, 2.01–3, 3.01– 4, and 4.01–5. Following
Altman (1991), kappa values of .41–.60 indicate moderate agreement,
.61–.80 indicate good agreement, and .81–1.00 indicate very good
agreement. All correlation coefficients and kappa values were statis-
tically significant at p ⬍ .001. However, the cognitive component
showed weaker associations with the other components than did the
physiological, behavioral, and emotional components with each other.
Pearson r correlations were inflated compared to kappa values be-
cause they were more strongly influenced by the relatively large
number of people with no fear indicated across all the anxiety and fear
components.
Reliability analysis. Overall, reliability of the final eight-item
scale was good. Internal consistency was high (Cronbach’s ␣ ⫽
.91), CITCs ranged from .65 to .89, and the intraclass correlation
(single measures) was .65, 95% CI [.63, .67]. Test–retest reliability
at 4-month follow-up was .82, which is high.
Evidence for validity. Correlations between the IDAF-4C
and its components and the DAS and SIDF measure are shown in
Table 3. The IDAF-4C was highly correlated with the DAS and
had a moderate correlation with the SIDF measure. Given the
emphasis of both the DAS and the SIDF measure on the emotional
element of the anxiety response, it is not surprising that the
Table 2
Associations (Pearson r Correlations and ␬) Between the Four
Components of the IDAF-4C
Component 1 2 3 4
1. Cognitive — .67 .61 .71
2. Physiological .48 — .81 .89
3. Behavioral .40 .77 — .79
4. Emotional .49 .86 .79 —
Note. Pearson r correlations appear above the diagonal; kappa with
quadratic weighting correlations appear below the diagonal. IDAF-4C ⫽
Index of Dental Anxiety and Fear core fear module.
component of the IDAF; DAS ⫽ Dental Anxiety Scale; SIDF ⫽ single-
item dental fear measure.
emotional component of the IDAF-4C had the highest correlations
with the DAS (r ⫽ .83, p ⬍ .001) and SIDF measure (r ⫽ .59, p ⬍
.001). The cognitive component of the IDAF-4C had the lowest
correlations with both the DAS (r ⫽ .60, p ⬍ .001) and SIDF
measure (r ⫽ .37, p ⬍ .001).
The IDAF-4C, DAS, and SIDF measure were compared across
phobia diagnosis categories for each of the three phobia diagnoses
derived from the phobia module. All fear measures were significantly
associated with the phobia diagnoses; however, the strength of the
association (determined using partial eta squared) was approximately
2 times greater for the DAS than for the SIDF measure and approx-
imately 2 times greater for the IDAF-4C than for the DAS. While the
DAS accounted for 13.3%, 5.2%, and 2.0% of the variance in the
P-DENT, P-DSMR, and P-DSMS diagnoses, respectively, the mea-
sures of association were 27.5%, 12.5%, and 5.4%, respectively, for
the IDAF-4C. The SIDF measure accounted for 6.9%, 1.2%, and
0.5%, respectively, in phobia diagnoses.
Correlation coefficients between each of the three fear measures
(SIDF, DAS, and IDAF-4C) and self-rated oral health were all low
but statistically significant and ranged between .17 and .21. The
associations between the three fear measures and several visiting
characteristics are shown in Table 4. All dental fear measures were
significantly associated with dental avoidance, avoidance due to fear,
frequency of dental visits, and usual reason for a dental visit. Across
most of these visiting characteristics, the IDAF-4C accounted for a
greater percentage of the variance than did the DAS, which accounted
for a greater percentage of the variance than did the SIDF measure.
Finally, the predictive capacity of the IDAF-4C was assessed by
examining scale scores with both dental visiting and perception of
the visit at 4-month follow-up. People who had visited a dentist in
the 4-month period between baseline and follow-up (n ⫽ 191, M ⫽
1.55, SD ⫽ .82) had significantly lower IDAF-4C scores than did
people who had not visited a dentist (n ⫽ 303, M ⫽ 1.91, SD ⫽
1.05), F(1, 492) ⫽ 16.50, p ⬍ .001. Of those people who had
visited a dentist at 4-month follow-up, there was a statistically
significant correlation between baseline dental fear and the per-
ception of the visit as negative (r ⫽ .37, p ⬍ .001).
Phobia Module
Individual items in the phobia module were endorsed by be-
tween 3.9% and 6.0% of participants. For each item, those who
 284 ARMFIELD

Table 4
Mean (and 95% CI) SIDF, DAS, and IDAF-4C Scores by Visiting Characteristics

SIDF DAS IDAF-4C

Visiting characteristic n M 95% CI n M 95% CI n M 95% CI

Dental avoidance
No 355 1.43 [1.34, 1.52] 353 7.84 [7.52, 8.16] 356 1.34 [1.28, 1.41]
Yes 726 1.81 [1.73, 1.89] 720 9.93 [9.68, 10.20] 726 2.03 [1.96, 2.11]
p ⬍ .001, ␩ ⫽ .028
2
p ⬍ .001, ␩ ⫽ .077
2
p ⬍ .001, ␩ ⫽ .113
2

Dental avoidance due to fear

No 952 1.52 [1.46, 1.58] 943 8.57 [8.38, 8.77] 953 1.59 [1.54, 1.64]
Yes 130 2.91 [2.69, 3.13] 130 14.16 [13.64, 14.68] 130 3.40 [3.25, 3.56]
p ⬍ .001, ␩ ⫽ .184
2
p ⬍ .001, ␩ ⫽ .264
2
p ⬍ .001, ␩ ⫽ .372
2

Frequency of dental visits

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2⫹ per year 249 1.41 [1.31, 1.51] 247 8.18 [7.78, 8.57] 249 1.48 [1.38, 1.58]
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1 per year 324 1.51 [1.40, 1.62] 322 8.75 [8.38, 9.12] 324 1.64 [1.54, 1.73]
1 per 2 years 173 1.83 [1.68, 1.98] 172 9.65 [9.13, 10.17] 173 1.95 [1.81, 2.08]
⬍1 per 2 years 313 2.04 [1.90, 2.18] 309 10.35 [9.93, 10.77] 313 2.15 [2.03, 2.26]
p ⬍ .001, ␩2 ⫽ .061 p ⬍ .001, ␩2 ⫽ .063 p ⬍ .001, ␩2 ⫽ .085
Usual reason for dental visit
Check-up 602 1.48 [1.41, 1.59] 595 8.33 [8.07, 8.59] 602 1.56 [1.49, 1.62]
Problem 460 1.97 [1.86, 2.08] 457 10.45 [10.11, 10.79] 460 2.13 [2.03, 2.23]
p ⬍ .001, ␩2 ⫽ .053 p ⬍ .001, ␩2 ⫽ .086 p ⬍ .001, ␩2 ⫽ .086
Future appointment made
Yes 162 1.56 [1.40, 1.72] 162 8.77 [8.24, 9.29] 162 1.65 [1.50, 1.79]
No 771 1.65 [1.58, 1.72] 764 9.14 [8.89, 9.39] 771 1.78 [1.71, 1.85]
p ⫽ .001, ␩2 ⫽ .001 p ⫽ .217, ␩2 ⫽ .002 p ⫽ .103, ␩2 ⫽ .003

Note. SIDF ⫽ single-item dental fear measure; DAS ⫽ Dental Anxiety Scale; IDAF-4C ⫽ Index of Dental Anxiety and Fear; CI ⫽ confidence interval.

responded that the statement applied to them had significantly
higher dental fear and greater avoidance of the dentist due to fear
than did those people who responded that the item did not apply to
them (see Table 5). The prevalence of a strict DSM–IV diagnosis
for dental phobia (including the belief that the fear is excessive or
unreasonable) not better accounted for by another psychological
disorder was 0.9%. The prevalence of dental phobia not better
accounted for by another psychological disorder but disregarding
the criterion that the person admits his or her fear to be excessive
or unreasonable was 2.2%. Finally, the prevalence of a phobia or
disorder with a dental component was 4.9%.
Test–retest reliability at 4 months for the three diagnostic items
was good, ranging from .57 to .67. Items related to the differential
diagnosis of panic disorder and social phobia had test–retest co-
efficients of .53 and .28, respectively. While diagnosis of P-DENT
at baseline had a correlation of .69 ( p ⬍ .001) with the diagnosis
at 4-month follow-up, the correlation for P-DSMR was lower at .27
( p ⬍ .001), and the test–retest for P-DSMS was not significant.

Table 5
Dental Fear and Avoidance by Responses to Phobia Module Items

IDAF-4C Avoidance due to fear

Phobia item n M 95% CI n % 95% CI

Interference with life

Yes 53 3.22 [2.91, 3.53] 53 51.4 [37.7, 65.1]
No 1,027 1.73 [1.68, 1.79] 1,027 10.0 [8.2, 11.7]
Distress at fear
Yes 48 4.00 [3.79, 4.20] 48 69.3 [56.1, 82.4]
No 1,032 1.70 [1.65, 1.75] 1,032 9.3 [7.5, 11.1]
Excessive/unreasonable
Yes 47 3.57 [3.25, 3.89] 47 61.6 [47.5, 75.7]
No 1,032 1.73 [1.67, 1.78] 1,032 9.8 [8.0, 11.6]
Afraid of panic attack
Yes 42 3.69 [3.41, 3.97] 41 69.3 [55.1, 83.5]
No 1,038 1.73 [1.67, 1.78] 1,038 9.7 [7.9, 11.5]
Socially anxious or afraid
Yes 65 2.71 [2.42, 2.99] 64 35.2 [23.4, 47.0]
No 1,015 1.75 [1.69, 1.81] 1,015 10.5 [8.6, 12.4]

Note. IDAF-4C ⫽ Index of Dental Anxiety and Fear core fear module; CI ⫽ confidence interval.
 DEVELOPMENT OF A DENTAL FEAR SCALE
Stimulus Module
There was considerable variation in the endorsement (at least
“a little” anxiety) of items making up the stimulus module. Highly
endorsed items (⬎75%) were painful or uncomfortable proce-
dures, cost of dental treatment, and needles or injections. Moder-
ately endorsed items (45%–55%) were not being in control, numb-
ness caused by the anesthetic, not knowing what the dentist was
going to do, gagging or choking, and having an unsympathetic or
unkind dentist. Less commonly endorsed items (⬍30%) were
feeling embarrassed or ashamed and feeling sick, queasy, or dis-
gusted.
All stimulus items correlated significantly with dental fear as
measured by the IDAF-4C. The lowest correlation was for the cost
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item, with a Pearson r correlation of .28. All other stimulus items
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had correlation coefficients with dental fear of between .41 (feel-
ing embarrassed or ashamed when at the dentist) and .71 (painful
or uncomfortable procedures when at the dentist). Test–retest
reliability of all items ranged from .55 (feeling sick, queasy, or
disgusted) to .73 (painful or uncomfortable procedures).
Discussion
This study aimed to develop and then assess the psychometric
properties of a dental fear scale (IDAF-4C⫹) in a representative
Australian adult population. Both reliability and validity were
assessed via several approaches. The dental anxiety and fear mod-
ule (designated the IDAF-4C) of the new scale demonstrated high
internal consistency and test–retest reliability over a period of 4
months. The scale items also showed good validity in terms of test
score interpretations, being associated with existing dental fear
scales and showing stronger associations with dental visiting char-
acteristics than two other dental fear scales currently used in dental
fear research.
The IDAF-4C⫹ adopts a modular approach, allowing research-
ers or clinicians to select for use the modules of interest or
relevance to them. While the eight-item core dental anxiety and
fear module occupies the center point of the larger scale, the
phobia module may be of use in those situations where a prelim-
inary diagnosis of a psychological or psychiatric condition is
desired. The stimulus module, in contrast, may aid where addi-
tional information about some of the important elements of an
individual’s dental fear is desired. Both the phobia and stimulus
modules add extra information to that gathered through the core
anxiety and fear module but are not requisite elements in deter-
mining a person’s fear per se.
The IDAF-4C⫹ was designed with several possible roles in
mind, and these have influenced its development. Primarily, the
scale was designed to assess an individual person’s level of dental
fear and anxiety via the core eight-item fear module. Dental fear
scales are used in diverse settings, from the dental clinic, where
they might be used to screen individual dental patients for their
level of fear, to questionnaire- or telephone-based epidemiological
investigations examining population prevalence. In the latter in-
stance, space or time constraints usually mean that long scales are
impractical or undesirable. For this reason, the IDAF-4C was
created so as to be practical to administer but without abandoning
either fundamental psychometric principles concerning scale de-
sign or the theoretical foundations on which the scale is based.
285
While the Dental Anxiety Inventory (DAI; Stouthard, Hoogstraten,
& Mellenbergh, 1995; Stouthard et al., 1993), for example, was
also developed using an underlying theoretical approach similar to
that guiding the development of the IDAF-4C, the original DAI
comprises an unwieldy and impractical 36 items (Stouthard et al.,
1993), and the derived short form represents a significant move
away from its theoretical origins (Armfield, in press).
Clinicians, more than epidemiologists, may find considerable
value in dental fear scales that incorporate ratings for individual
stimuli that a person may be afraid of. This desire explains,
perhaps, the enduring popularity of the Dental Fear Scale
(Kleinknecht, Klepac, & Alexander, 1973), which has nested
within its 20 items what is effectively a 12-item stimulus checklist.
The modular approach of the IDAF-4C⫹ therefore allows for a
separate stimulus list of some of the most common and widely
acknowledged fearful stimuli associated with going to the dentist.
It is believed that the stimulus module could be of benefit to
researchers, dentists, psychologists, or psychiatrists who are inter-
ested in determining not just the level of a person’s fear but also
exactly what aspects of going to the dentist are most troubling for
an individual. For example, identification of dental injection fear
would allow a dentist to further explore the specific dimensions
of this fear, which might suggest strategies to address the
patient’s relevant concerns (Milgrom, Coldwell, Getz, Weinstein,
& Ramsay, 1997).
While the use of DSM–IV diagnostic criteria in the phobia
module provides a significant advance on other dental fear and
anxiety scales that use cutpoints as an indication of a potentially
phobic individual, it should still be noted that this module has not
been validated against clinical diagnoses and also that it cannot be
regarded as a clinical diagnosis. A questionnaire-based diagnostic
protocol could only ever aim to approximate a diagnosis by a fully
qualified and experienced psychologist or psychiatrist. Future
work in this area will explore the capacity of the five-item phobia
module, used in conjunction with the computed dental fear score
from the core anxiety and fear module, to effectively ascertain the
phobic status of an individual. In particular, the lack of a statisti-
cally significant association between the P-DSMS diagnosis at
baseline and follow-up requires further investigation. It is apparent
from the results that adding extra criteria to the questionnaire-
based diagnosis produced a stepwise worsening of the test–retest
results. However, the reason for this could not be ascertained. In
any event, these findings underline that the phobia module as it
currently stands should be regarded as merely a screening tool for
dental phobia and not a diagnosis in and of itself.
The IDAF-4C had moderate to high correlations with both
Corah’s DAS, the most commonly used measure of dental fear,
and a single-item measure of dental fear. Promisingly, however,
the IDAF-4C had stronger associations with both dental phobia
diagnosis and visiting characteristics than the other two dental fear
scales. In terms of explaining the variance in avoidance of the
dentist due to fear, the IDAF-4C explained an additional 10.8% of
the variance over the DAS, which itself explained an additional 8%
of the variance over a psychometrically untested single-item mea-
sure. These results suggest that the IDAF-4C might represent a
significant improvement over these other scales in terms of pre-
dicting some clinically relevant outcomes.
One of the major advantages of the IDAF-4C over most existing
scales is that it assesses the multidimensional nature of anxiety and
 286 ARMFIELD
fear. While the same result might be achievable by combining
some existing dental anxiety scales, the practical, methodological,
and theoretical problems associated with this approach make the
eight-item IDAF-4C a superior option. The IDAF-4C not only
serves the useful purpose of highlighting the multidimensional
nature of the anxiety and fear construct but also standardizes the
combination.
Despite the strengths of the new scale and the findings of this
study, several limitations should also be noted. One limitation is
that the current study relied entirely upon self-report instruments
of dental fear and visiting patterns. More research is needed to
examine the relationship between the IDAF-4C⫹ and observation-
and behavior-based instruments related to dental fear. Although a
phenomenological perspective is important in understanding and
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
measuring dental fear, further validation evidence using clinician
ratings or behavior-based scales would be of considerable value. In
addition, cross-validation in different cultural settings is needed.
The current study used Australian adults, and while empirical
evidence suggests relatively similar levels of dental fear across
many countries, it may still be the case that cultural differences are
present in relation to both the level of dental anxiety and fear and
the internal structure of the dental anxiety and fear construct.
In terms of the favorable comparisons of the IDAF-4C with
other dental fear scales, especially the DAS, it should be noted that
even though the DAS is the most widely used measure of dental
fear currently reported in the literature (Armfield, in press), it is
also widely acknowledged to be a flawed scale in several ways.
Because of this, a modified version of the scale (MDAS; Humphris
et al., 1995) has been developed. While the IDAF-4C has been
shown in this study to compare favorably to the DAS and despite
the MDAS still suffering from the same limited theoretical foun-
dations as the DAS, it would also be useful to look at how the
IDAF-4C compares to the psychometrically improved MDAS. In
addition, it would be worthwhile to compare the relative advan-
tages and disadvantages of the IDAF-4C with the DAI (Stouthard
et al., 1993, 1995), which is also theoretically based.
Finally, given the correlational nature of the data presented here,
it should be remembered that no conclusions can be drawn regard-
ing causality. Future research on the association between dental
fear, oral health, and treatment-seeking behavior should examine
the extent to which this new measure of dental anxiety and fear is
(a) related to changes in oral health and treatment seeking over
time, (b) associated with the outcome of various types of dental
treatment, and (c) sensitive to change across a course of care
undertaken by a dentist or dental auxiliary. In addition, the causal
associations between dental fear, the development of a phobia, and
fear of particular stimulus characteristics of dental visits have not
yet been adequately explored, and these should be further pursued.
In summary, despite the necessity for further evidence of valid-
ity and cross-cultural appropriateness, the IDAF-4C⫹ presents a
promising approach to measuring dental anxiety and fear, balanc-
ing the needs for practicality and flexibility with a strong, explicit
theoretical underpinning that takes into account the four compo-
nents of the anxiety and fear response set. More than this, there is
evidence that in some regards, the new scale offers almost as much
additional exploratory power over Corah’s widely used DAS as the
DAS offers over a single-item global scale. This is consistent with
the expanded operationalization of the fear construct provided by
the four components of the anxiety and fear response set. While the
added sensitivity of the scale will only be known after further
research, initial indications appear promising.
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Received July 21, 2009
Revision received December 3, 2009
Accepted December 7, 2009 䡲