Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 16–22
ADRF RESEARCH REPORT
doi: 10.1111/j.1834-7819.2010.01279.x

Australian population norms for the Index of Dental Anxiety

and Fear (IDAF-4C)
JM Armfield* 
*Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia, Australia.
 Department of Dental Public Health Sciences, School of Dentistry, University of Washington, USA.

ABSTRACT
Background: The Index of Dental Anxiety and Fear (IDAF-4C) is a theoretically derived test developed to allow clinicians
and researchers to measure a person’s level of dental fear. Population norms have not previously been made available for the
IDAF-4C. The aim of this study was to provide Australian norms for the IDAF-4C using percentile ranks and to examine
associations between scores and individual-level characteristics, dental avoidance and fear of pain.
Methods: A stratified random sample of 1511 Australian adults yielded complete questionnaire data for 1063 individuals
(70.4%). Percentile ranks were calculated for IDAF-4C full scale scores stratified by age and gender.
Results: IDAF-4C mean scores varied significantly by age, gender, income, and speaking a language other than English at
home. Tables to convert raw scores to percentiles showed that full scale scores varied by age and gender. Scores on the
IDAF-4C had strong and significant associations with avoidance of the dentist due to fear, average dental visiting frequency
and anxiety about pain when going to the dentist.
Conclusions: Population norms allow clinicians or researchers to compare results for an individual or subgroup to the
Australian population. It is recommended that a dental fear scale be used to screen all dental patients for dental fear to
enable a more tailored and effective dental treatment experience.
Keywords: Dental anxiety, population norms, fear, scale construction.
Abbreviations and acronyms: CATI = computer-assisted telephone interview; ERP = estimated resident population; IDAF-4C = Index of
Dental Anxiety and Fear; NDAFS = National Dental Anxiety and Fear Survey; NDTIS = National Dental Telephone Interview Survey.
(Accepted for publication 26 April 2010.)

dentists identified as having a special interest in treating

INTRODUCTION
Dental fear is common among Australians visiting the
dentist. It is estimated that approximately one in six
Australians have high levels of dental fear and among
some segments of the population the prevalence can be
as high as 35%.1 Studies in Australia and elsewhere
have found that high levels of dental fear are associated
with reduced dental attendance, appointment cancella-
tions2,3 and with various patient behavioural compli-
cations4 and associated stress for the attending dentist.5
People with high dental fear have also been found to
have poorer oral health.6,7
Although there are numerous consequences of dental
fear for both the dental practitioner and afflicted
individual, there is little evidence that Australian
dentists ever systematically screen for dental fear. One
study in the United Kingdom found that even among
16
dental fear, only 20% employed a standardized screen-
ing questionnaire to ascertain a patient’s level of dental
fear.8 An understanding of the level of a patient’s fear
may be revealed through either a case history or
through observation of a patient’s behaviour. However,
even if these methods successfully ascertain pre-existing
dental fear, this knowledge may end up being a result of
the treatment process rather than a guide to treatment
decisions, providing little opportunity to ameliorate the
patient’s fear. Ideally, dentists should diagnose the
condition prior to determining effective fear-reduction
strategies.9
Several dental fear and dental belief scales have been
developed and could be used to measure dental fear in
the clinic. However, these scales have been variously
criticized for their poor construction, validity and
theoretical background.10–12 To redress several
ª 2010 Australian Dental Association

perceived issues with these measures, a theoretically-based
dental fear scale was recently developed specifically for
the purposes of both clinicians and researchers.13 The
full Index of Dental Anxiety and Fear (IDAF-4C+) has
three modules, each of which can be used depending on
the intentions or needs of the user. In particular, the
8-item base module that measures dental anxiety and
fear IDAF-4C (see Appendix for scale) may be relevant
to clinicians who wish to use a general screening
questionnaire for dental fear.
The availability of population norms is considered
important for published psychological tests.14,15 Norms
allow clinicians or researchers to quantify the rarity or
prevalence of a patient’s score or response relative to
the overall population.16 Population norms can also be
used by researchers to compare study samples for the
purpose of comparing different populations and sub-
populations, interpreting outcomes in intervention
studies, or tracking population shifts over time.17 While
test norms and percentile ranks have been provided for
some other dental fear scales,18 none have as yet been
reported for the IDAF-4C. To this end, the aims of the
study were to firstly provide Australian population
norms for the IDAF-4C and secondly to examine the
association of IDAF-4C scores with selected aspects and
consequences of dental fear, to enable both clinicians
and researchers to better interpret IDAF-4C scores.
METHODS
Sample
Data were obtained from the National Dental Anxiety
and Fear Survey (NDAFS) conducted in 2008. The
survey was cross-sectional in design and employed a
questionnaire mail-out to a stratified, random selection
of Australian adults (aged 18 years or over) from all
states and territories of Australia. All participants in the
survey had previously completed the larger National
Dental Telephone Interview Survey (NDTIS) which is a
computer-assisted telephone interview (CATI) survey
conducted by the Australian Research Centre for
Population Oral Health and funded by the Australian
Government Department of Health and Ageing. The
NDTIS used 15 strata which comprised the capital city
and rest-of-state of New South Wales, Victoria,
Queensland, Western Australia, South Australia, Tas-
mania and the Northern Territory. A single stratum
was used for the Australian Capital Territory. Stratified
sampling from the Australian electoral roll was used.
The electoral roll contained information on all regis-
tered voters in Australia in 2007. Approximately 13.6
million or 93% of Australian adults were registered to
vote in early 2008.19
A random sample of one in four respondents to the
NDTIS was made available for sampling for the nested
ª 2010 Australian Dental Association
Index of Dental Anxiety and Fear
NDAFS. The random sample was calculated using a
random number generator and was restricted to 25%
due to budgeting and other logistical constraints.
Selected individuals were sent a cover letter and
questionnaire followed by a reminder card approxi-
mately two weeks later and a repeat questionnaire
another two weeks later if no response had been
received. All materials were written in English. The
initial mailout was conducted between April and
August 2008 while repeat questionnaires were sent
out between May and September 2008. The cover letter
contained information about the study as well as
assurances of the participants’ anonymity and the
confidentiality of responses. Reply-paid envelopes were
provided to participants for questionnaire returns.
No incentive was provided for participating in the
study. The response rate approximately two weeks after
the first wave of questionnaires were sent out was 36%,
which increased to approximately 72% after the second
wave of questionnaires.
Materials
The IDAF-4C (see Appendix) contains eight statements
with possible responses measured on a 5-point scale
from ‘disagree’ (1) to ‘strongly agree’ (5).13 The scale
has two items pertaining to each of the emotional,
behavioural, cognitive and physiological components of
the fear and anxiety response set. Full scale scores can
be obtained by either summing the item scores (range:
8–40) or by obtaining the average of the items scores
(range: 1–5). The IDAF-4C has high internal consis-
tency (Cronbach a = 0.91), good test-retest reliability
(r = 0.82) and has demonstrated concurrent and pre-
dictive validity.13
Additional information on fear of pain and avoid-
ance of the dentist due to fear was available from the
NDAFS questionnaire. Participants were asked ‘to what
extent are you anxious when you go to the dentist’ of
‘painful or uncomfortable procedures’, with possible
responses being ‘not at all’, ‘a little’, ‘somewhat’,
‘moderately’ or ‘very much’. Information on socio-
demographic, socio-economic and dental visiting
information was available from the NDTIS CATI.
Respondents provided information regarding their age
and gender as well as their estimated annual household
income, highest level of education attained, whether or
not they spoke a language other than English (LOTE) at
home, and their dental visiting frequency. In relation to
dental visiting, participants were asked ‘how long ago
did you last see a dental professional about your teeth,
dentures or gums?’. Possible responses were
‘<12 months’, ‘1 – <2 years’, ‘2 – <5 years’, ‘5 – <10
years’, ‘10 + years’, ‘never’ or ‘don’t know’. Responses
to the question on time since last visit were dichoto-
mized to either <2 years or 2+ years.
17
JM Armfield

Analyses Table 1. Comparison of demographic characteristics

of the unweighted and weighted sample to the
Full scale scores for the IDAF-4C were reported both as
Australian population
a sum score and an average score. Because dental fear
has previously been found to vary by individual-level Sample (weighted) Australia
characteristics, full scale scores were analysed by (2006)
several socio-demographic and socio-economic vari- n % 95% CI %
ables. Percentile ranks for scale scores were calculated
Gender
as these have been recommended as a useful and Male 519 48.7 43.9–53.4 48.7
relatively simple approach that allows a clinician to Female 548 51.3 46.6–56.1 51.3
evaluate an individual patient’s score against the Age
18–24 205 19.2 15.2–24.0 12.4
distribution of scores for a particular population or 25–39 259 24.3 19.6–29.6 27.5
sub-population.20,21 Expressing a given score as above 40–64 423 39.7 35.5–44.0 42.6
a particular percentile rank, rather than using specific 65+ 180 16.9 14.6–19.4 17.5
State or Territory of residence
cut-offs, is also consistent with the now commonly held New South Wales 357 33.4 28.7–38.5 33.0
view that anxiety is a unidimensional, rather than a Victoria 269 25.2 21.3–29.5 25.1
categorical, construct.22 Percentile ranks were stratified Queensland 212 19.8 16.4–23.8 19.4
South Australia 73 6.8 5.5–8.5 7.8
by age and gender because these variables have been Western Australia 109 10.2 7.9–13.1 9.8
previously found to be associated with dental fear1 and Tasmania 24 2.3 1.8–2.9 2.4
they are easily ascertainable by a dental practitioner or Australian Capital 17 1.6 1.1–2.2 1.7
Territory
researcher. Northern Territory 7 0.7 0.4–1.1 0.9
All data were weighted to the within-strata age and Level of education 
gender estimated resident populations (ERPs) of Aus- Postgraduate 77 7.2 4.8–10.6 2.6
Bachelor 190 17.8 14.3–21.9 11.6
tralia’s states and territories using census data from the Graduate certificate ⁄ 153 14.3 11.6–17.6 8.5
Australian Bureau of Statistics. diploma
Certificate 227 21.2 18.0–24.9 16.7
Other 422 39.5 34.9–44.3 60.6
Ethics  Australian data includes people aged 15 years or older.
Ethical approval for the conduct of the NDAFS was
obtained from the University of Adelaide Human The mean summed IDAF-4C score was 14.40 (95%
Research Ethics Committee while ethical approval for CI = 13.93–14.86) and the mean averaged score was
the NDTIS was obtained from both the University of 1.80 (95% CI = 1.74–1.86). Table 2 shows the mean
Adelaide Human Research Ethics Committee and the full scale scores for the IDAF-4C by age, gender,
Ethics Committee of the Australian Institute of Health income, educational attainment and LOTE. There
and Welfare. was variation in IDAF-4C scores for all the socio-
demographic and socio-economic characteristics.
Females, adults aged 25 years and older, people with
RESULTS
lower income and participants who spoke a language
A total of 1511 Australian adults were approached other than English at home had statistically higher
to participate in the NDAFS and there were 1084 dental fear. However, the variation in scores across
respondents. Approximately 2% of participants categories of highest achieved level of education was
(n = 21) missed responding to one or more items in not statistically significant (p = 0.10).
the IDAF-4C. Data from these respondents were Table 3 provides percentile ranks for IDAF-4C
excluded from the analyses meaning that complete scores stratified by age group and gender. The table
data were available for 1063 individuals (70.4%). can be used by locating any score (whether for an
Table 1 provides a comparison of selected demo- individual person or a mean for a population sample
graphic and socio-demographic characteristics of the or subgroup) for a particular age and gender and
weighted final sample with those of the Australian reading back to the percentile in the left-most
population from 2006. The pattern of results for the column. For example, a summed score of 25 for
gender, age and residence distribution of the sample a 58-year-old male would yield a percentile rank of
closely matched the characteristics of the Australian 90 or 91, which would place that person’s dental fear
population from the 2006 national census. The score in the top 10% of scores for that age and
exceptions were that the weighted sample slightly gender demographic. It is apparent from the table
over-represented younger adults (aged 18–24) and that the distribution of scores and therefore the
under-represented people with only a secondary percentile rank for any one score varies by both the
education. age and gender group.

18 ª 2010 Australian Dental Association

 Index of Dental Anxiety and Fear

Table 2. IDAF-4C norms by socio-demographic, socio- Table 3. Percentiles for summed and averaged
economic and dental visiting characteristics IDAF-4C scores by age group and gender
Weighted % Summed IDAF-4C score Percentiles Age group
n
Mean SD 95% CI 18–24 25–39 40–64 65+

Gender*** Sum Ave. Sum Ave. Sum Ave. Sum Ave.

Male 519 48.6 13.56 6.98 12.96,14.16
Female 548 51.4 15.20 8.28 14.51,15.89 Males (n = 102) (n = 124) (n = 207) (n = 86)
Age (years)* 20 8 1.00 8 1.00 8 1.00 8 1.00
18–24 205 19.2 12.87 6.50 11.98, 13.76 40 9 1.13 11 1.38 10 1.25 9 1.13
25–39 259 24.3 14.88 7.73 13.93, 15.82 50 11 1.36 13 1.58 11 1.50 10 1.25
40–64 423 39.6 14.83 7.98 14.07, 15.59 60 12 1.47 16 2.00 12 1.63 11 1.38
65+ 180 16.9 14.47 8.16 13.28, 15.66 70 14 1.75 18 2.25 14 1.88 13 1.63
Income (per annum)* 75 15 1.88 22 2.75 15 2.10 14 1.75
<$30K 182 18.5 15.90 8.42 14.67, 17.12 80 15 1.88 22 2.75 17 2.47 17 2.13
$30K–<$60K 254 25.8 13.74 7.10 12.87, 14.62 85 15 1.88 24 3.00 21 2.95 20 2.48
$60K–<$90K 242 24.5 14.33 7.72 13.36, 15.30 90 17 2.13 24 3.00 25 3.29 27 3.37
$90K+ 308 31.2 13.81 7.11 13.01, 14.60 91 17 2.13 24 3.00 25 3.75 27 3.39
Level of education 92 17 2.13 25 3.13 26 3.88 28 3.50
Year 10 181 17.0 15.34 8.62 14.08, 16.59 93 19 2.36 27 3.37 30 3.91 30 3.71
Year 12 237 22.3 14.58 7.98 13.56, 15.60 94 19 2.38 33 4.13 31 4.01 32 4.05
Certificate ⁄ 380 35.7 14.36 7.59 13.60, 15.12 95 20 2.49 33 4.13 32 4.13 33 4.13
diploma 96 22 2.74 34 4.25 33 4.13 35 4.34
Undergraduate 190 17.8 13.23 6.10 12.36, 14.10 97 26 3.20 34 4.25 33 4.24 35 4.38
Postgraduate 77 7.2 14.99 8.63 13.05, 16.92 98 34 4.25 34 4.25 35 4.53 35 4.38
LOTE at home* 99 34 4.25 34 4.25 37 4.63 38 4.77
No 134 11.2 15.67 7.63 14.37, 16.96 Females (n = 103) (n = 135) (n = 216) (n = 94)
Yes 934 88.8 14.22 7.71 13.73, 14.72 20 8 1.00 8 1.00 9 1.13 9 1.13
TOTAL 1,068 100.0 14.40 7.71 13.93, 14.86 40 9 1.13 11 1.38 11 1.38 11 1.35
50 10 1.25 11 1.38 13 1.63 12 1.50
ANOVA: *p < 0.05, ***p < 0.001. 60 12 1.50 13 1.63 15 1.88 14 1.75
70 15 1.88 16 2.00 18 2.25 18 2.25
75 17 2.13 17 2.13 21 2.58 20 2.54
Table 4 shows the percentage of the normative 80 20 2.50 19 2.38 23 2.91 24 2.94
sample, stratified by age, gender and dental fear score, 85 23 2.82 22 2.72 28 3.53 26 3.26
90 27 3.38 28 3.50 31 3.88 31 3.89
who responded that they avoid going to the dentist due 91 27 3.38 30 3.74 32 4.00 32 4.00
to their level of fear, who visit the dentist less than every 92 30 4.74 33 4.13 32 4.00 33 4.06
two years on average or who were somewhat to very 93 32 4.00 33 4.14 32 4.00 34 4.22
94 32 4.01 34 4.25 33 4.12 34 4.25
anxious about painful or uncomfortable procedures 95 33 4.13 34 4.25 34 4.23 36 4.45
when going to the dentist. There was a strong 96 33 4.13 34 4.25 35 4.42 37 4.67
correspondence between higher scores on the 97 33 4.13 36 4.50 36 4.50 38 4.75
98 33 4.13 37 4.63 37 4.63 38 4.75
IDAF-4C and dental avoidance, visiting frequency, 99 35 4.37 39 4.88 38 4.71 38 4.75
and anxiety about pain. For example, among people
with a score of between 32 and 40 on the IDAF-4C, Note: The percentile rank of a score for a person of a particular age
and gender is the percentage of scores in the frequency distribution
almost two-thirds reported that they avoided going to that are lower than it.
the dentist because of their fear, approximately 36%
reported last visiting a dentist two or more years
previously, and over 90% expressed anxiety about pain
DISCUSSION
or discomfort. There were also several differences
across age and gender categories. People aged between It is important when interpreting any test or scale result
18 and 24 years were less likely to avoid going to the that the test user understands what the scale evaluates,
dentist due to their fear, while among those people with its precision in evaluation, any margins of error
IDAF-4C scores between 32 and 40, people aged involved in scoring, and what the individual scores
40 years or older were almost twice as likely to avoid mean in the context of overall test norms and the
the dentist due to fear as were 18–24 year olds, and specific background of the individual. Raw scores
those people aged between 25 and 39 were almost three become meaningful mainly in relation to norms which
times more likely to avoid the dentist due to fear as are an independently established frame of reference
were 18–24 year olds. Females with an IDAF-4C score derived from a standardization sample.23 In terms of
between 24 and 31 were more likely than males to assessment criteria for scale development, establishing
avoid the dentist due to fear, but for IDAF-4C scores test norms can be considered to be as important as
between 32 and 40 almost 85% of males reported that determining the validity and reliability of scale
they avoid going to the dentist compared to only 55% scores.14,15 This paper adds to the information already
of females. available on the IDAF-4C regarding reliability and
ª 2010 Australian Dental Association 19
JM Armfield

Table 4. Percentage (%) of respondents by age, gender and IDAF-4C score range who report reduced dental visiting
and anxiety about painful or uncomfortable procedures when going to the dentist
Age Gender

18–24 25–39 40–64 65+ Male Female Total

% n % n % n % n % n % n % n

Avoidance due to dental fear

IDAF-4C score 8–15 0.0 165 3.0 164 1.4 290 3.1 129 2.1 390 1.4 359 1.7 750
IDAF-4C score 16–23 9.1 22 17.5 57 16.7 66 23.8 21 19.7 71 14.9 94 17.5 166
IDAF-4C score 24–31 28.6 7 33.3 21 57.1 35 60.0 15 35.5 31 56.3 48 48.1 79
IDAF-4C score 32–40 33.3 9 89.5 19 61.3 31 64.3 14 84.6 26 55.3 47 65.8 73
Last visit 2+ years ago
IDAF-4C score 8–15 10.0 150 29.3 164 14.7 290 22.4 128 24.8 374 11.8 358 18.4 734
IDAF-4C score 16–23 13.0 23 25.0 56 13.4 66 36.4 22 22.5 71 17.9 95 19.9 166
IDAF-4C score 24–31 12.5 8 45.0 20 15.8 35 23.5 16 20.6 32 26.0 48 23.8 80
IDAF-4C score 32–40 30.0 10 47.4 19 25.8 31 46.2 13 29.6 27 39.6 48 36.5 74
Anxious about pain
IDAF-4C score 8–15 9.0 166 14.6 164 6.3 288 7.0 129 4.6 389 13.2 357 8.8 748
IDAF-4C score 16–23 40.9 22 46.4 56 48.5 66 38.1 21 39.4 71 49.5 95 45.5 165
IDAF-4C score 24–31 71.4 7 95.0 20 72.2 36 56.3 16 78.1 32 72.9 48 75.0 80
IDAF-4C score 32–40 100.0 10 100.0 19 90.3 31 85.7 14 92.3 26 93.6 47 93.2 74

validity13 by reporting test norms using percentile ranks
by both age and gender.
Higher scores on the IDAF-4C signal the possibility
of several aversive consequences. Dental fear is an issue
for the individual, for the treating dental staff, and for
the wider community. Individual people not only suffer
the negative emotional states of anxiety and fear but
often have to put up with the pain and discomfort of
dental disease stemming from the avoidance of going to
the dentist to seek treatment. For the dentist, people
with high dental fear often delay or cancel appoint-
ments, may require more time to treat, and may pose
various other challenges. For the wider community,
dental fear is a significant public health challenge given
that dental disease is one of the most common illness
complaints by adults and that both public and private
expenditure on preventing and treating dental disease is
considerable.
The percentile ranks reported in this paper allow a
clinician to compare scores for an individual to that
of an age and gender appropriate sub-population.
If examining a 45-year-old female with a score of 26
on the IDAF-4C, a clinician might ask how this score
compares against other similarly aged women in the
Australian population. Gauged against the percentile
distribution reported here, the score enables the dentist
to determine that the patient is in the top 20% of
similarly aged females in terms of their level of dental
fear. This technique is not only straightforward but has
been argued to be appropriate for data with non-
normal distributions,20,21 such as those produced by the
IDAF-4C.
In addition to the percentile rank, the dental fear
score itself is important to consider when interpreting
the significance of a score. This study found a strong
relationship between dental fear, as assessed by the
20
IDAF-4C, and aversive consequences. As IDAF-4C
scores increased so too did the frequency of self-
reported dental avoidance, time since last dental visit,
and anxiety over pain. Each of these consequences has
obvious implications for the dental practitioner and
these have been covered by sources that deal with
treating patients with high dental fear.9
While Australian dentists have been found to use a
wide variety of possible anxiety management pro-
cesses,24,25 there is currently no evidence of any
systematic or widespread effort by Australian dentists
or dental staff to first identify patients who have dental
fear. This is unfortunate as just the knowledge of a
patient’s fear has been shown to lead to reduced post-
treatment dental anxiety.26 In addition, using a dental
fear measure to assess patients’ concerns has been
argued to have the benefit of expediting and simplifying
communication between patients and dentists by
allowing patients to identify their fears on paper before
exploring them with their dentist.27
Dentists have a range of behavioural and treatment
options available to them so the identification of fear
using a simple paper-and-pencil scale would provide an
opportunity for a dentist to further explore with a
patient their issues and concerns and to determine
possible treatment approaches. Because dental fear is
such a pervasive barrier to obtaining improved oral
health, it is important the dentist does his or her part in
appropriately identifying and treating highly fearful
individuals. However, research is still required that tests
the effectiveness of using a dental fear scale against the
common clinical practise of taking a dental history as
an integral part of good clinical history taking and
patient management.
Although there are several measures of dental fear
available for use by clinicians, the IDAF-4C has been
ª 2010 Australian Dental Association

specifically developed to measure the physiological,
cognitive, emotional and behavioural components of
dental anxiety and fear. As such, it is a more
comprehensive dental fear measure than most other
available scales. It is also reasonably short, making it
more conducive for use in a dental surgery or clinic
where time may be limited. Indeed, even a single-item
dental fear question might be beneficial in screening
those patients who could benefit from a more in-depth
evaluation provided by a scale such as the IDAF-4C.
One word of caution is required in relation to the
interpretation of percentages reported in this paper.
Even though people with high levels of dental fear
might be much more likely to have problems with, for
example, pain or needles than people with a low level of
dental fear, this should not be interpreted as meaning
that someone with less anxiety cannot also have specific
concerns. Even with a relatively low IDAF-4C score
between 16 and 23, almost one-quarter of people aged
65+ reported avoiding going to their dentist as a result
of that level of anxiety and fear. And although only
13% of females with no or very little fear (scores
between 8 and 15) reported anxiety regarding pain or
discomfort, this still equates to almost 1 in 8 females.
Just because there is a lower probability of an aversive
consequence associated with a lower IDAF-4C score
does not mean that cases will not occur. It is urged that
all patients be treated as though they had dental fear
rather than the other way around. Uncovering specific
concerns regarding going to the dentist can serve as a
highly useful adjunct to an IDAF-4C score, and these
can be ascertained using instruments such as the
stimulus module of the IDAF-4C+ which covers anxiety
relating to pain or discomfort, embarrassment and
shame, lack of control, feeling sick or queasy, numbness
caused by the anaesthetic, not knowing what is going to
happen, the cost of treatment, needles or injections,
gagging or choking, and having an unkind dentist.
Although high scores on dental fear scales are known
to be associated with various clinical and behavioural
correlates,1–7 it is also the case that many times they will
not translate into avoidance of the dentist or clinical
anxiety behaviours. For example, many people with high
dental fear report that they regularly visit the dentist.2
Also, avoidance of the dentist may stem from various
other factors unrelated to dental fear. Time restraints, the
cost of dental care, beliefs about oral health benefits and
perceived need are all likely to be important determinants
of dental visiting patterns. In addition, personality
characteristics and coping strategies may play a role in
determining both dental visiting patterns and behaviour
while at the dentist.28 Dental anxiety and fear is only one
of several complex and interacting factors that can
potentially impact on avoidance behaviour.
Although this study used a reasonably large sample
of over 1000 Australian adults and weighted the sample
ª 2010 Australian Dental Association
Index of Dental Anxiety and Fear
age and gender distribution to that of the Australian
population, it is still the case that there will be
inaccuracy in the results due to sample selection.
In particular, the smaller numbers for some of the age
groups used when presenting percentile ranks suggests
the need for a more cautious interpretation of the
results. It should be appreciated therefore that the
percentile rankings presented here are not absolute but
should be used as a guide only for interpreting the
location of an IDAF-4C score relative to the distribu-
tion of scores for the corresponding age–gender demo-
graphic.
CONCLUSIONS
This study presented population norms for the
IDAF-4C. These norms allow dental professionals, staff
or researchers to compare individual or group scores to
determine where the score sits in relation to demo-
graphically (age and gender) comparable Australian
adults in the population. It is recommended that
dentists use a dental fear screening tool in order to
identify and better understand dental anxiety and fear
in their patient population and to assist in patient
management decisions.
ACKNOWLEDGEMENTS
This study was funded by a research grant from the
Australian Dental Research Foundation.
AUTHOR’S NOTE
Copies of the full scale as well as administration,
scoring and interpretation details can be obtained from
the author.
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Address for correspondence:
Dr Jason Armfield
Department of Dental Public Health Sciences
University of Washington
NE Pacific Avenue
Box 357475
Seattle
Washington 98195
USA
Email: jason.armfield@adelaide.edu.au

APPENDIX
The following questions ask about possible aspects of dental anxiety and fear.

How much do you agree with the following statements? Disagree Agree Somewhat Moderately Strongly
a little agree agree agree

(a) I feel anxious shortly before going to the dentist. h1 h2 h3 h4 h5

(b) I generally avoid going to the dentist because I find h1 h2 h3 h4 h5
the experience unpleasant or distressing.
(c) I get nervous or edgy about upcoming dental visits. h1 h2 h3 h4 h5
(d) I think that something really bad would happen to h1 h2 h3 h4 h5
me if I were to visit a dentist.
(e) I feel afraid or fearful when visiting the dentist. h1 h2 h3 h4 h5
(f) My heart beats faster when I go to the dentist. h1 h2 h3 h4 h5
(g) I delay making appointments to go to the dentist. h1 h2 h3 h4 h5
(h) I often think about all the things that might go h1 h2 h3 h4 h5
wrong prior to going to the dentist.

22 ª 2010 Australian Dental Association