From a common-sense point of view it is clear that some situations will arouse more
anxiety than others. For example, a fear of heights is relatively common, but it is
galling to note that in the United States a study by Agras et al. (1969) found that
visiting the dentist ranked fourth behind snakes, heights, and storms. Clearly then,
anxiety about dental care is a problem that we as a profession must take seriously,
especially as children remember pain and stress suffered at the dentist and carry the
emotional scars into adult life. Some people may develop such a fear of dentistry that
they are termed phobics. A phobia is an intense fear which is out of all proportion to
the actual threat.
Research in this area suggests that the extent of anxiety a person experiences does not
relate directly to dental knowledge, but is an amalgamation of personal experiences,
family concerns, disease levels, and general personality traits. Such a complex
situation means that it is no easy task to measure dental anxiety and pinpoint
aetiological agents.
Measuring dental anxiety is problematic because it relies on subjective measures,
plus the influence of the parents, the dentist's behaviour, and the reason for a visit may
all exert some effect on a child's anxiety levels.
Questionnaires and rating scales are the most commonly used means by which anxiety
has been quantified, although there has been some interest in physiological data such
as heart rate. Some questionnaires that have been used to measure anxiety can be
applied to a whole variety of situations, such as recording 'exam nerves' or fear of
spiders, while others are specific to the dental situation. The most widely used dental
anxiety measure is Corah's Dental Anxiety Scale (see Kent and Blinkhorn 1991),
which takes the form of a questionnaire. Patients are asked to choose an answer which
best sums up their feelings. The answers are scored from 1 to 5 so that a total score
can be computed. A high score should alert the dental team that a particular patient is
very anxious.
However, patient-administered questionnaires have a limited value in evaluating a
young child's anxiety because of their poorly developed vocabulary and
understanding. Therefore there has been great interest in measuring anxiety by
observing behaviour. One such scale was developed by Frankl to assess the effect of a
parent remaining with a child in the surgery (see Kent and Blinkhorn 1991). It
consists of four ratings from definitely negative to definitely positive. It is still
commonly used in paediatric dental research. Another scale which is popular with
researchers is one used by Houpt, which monitors behaviour by allocating a numerical
score to items such as body movement and crying (see Kent and Blinkhorn 1991).
Recent studies have used the Frankl scale to select subjects for studies, and then more
detailed behaviour evaluation systems are utilized to monitor the compliance with
treatment (see Kent and Blinkhorn 1991). Behavioural observation research can be
problematical as the presence of an observer in the surgery may upset the patient. In
addition, it is difficult to be totally objective when different coping strategies are
being used and some bias will occur. The development of cheap lightweight digital or
video cameras has greatly helped observational research, as the patient's behaviour
can be scored by a number of raters away from the surgery. Rescoring the videos is
also possible to check the reliability of the index used.