BMC Oral Health BioMed Central

Research article Open Access

The modified dental anxiety scale: UK general public
population norms in 2008 with further psychometrics and effects of
age
Gerry M Humphris*1, Tom A Dyer2 and Peter G Robinson2

Address: 1Health Psychology, Bute Medical School, University of St Andrews, UK and 2Department of Oral Health and Development, University
of Sheffield, Sheffield, UK
Email: Gerry M Humphris* - [email protected]; Tom A Dyer - [email protected]; Peter G Robinson - [email protected]
* Corresponding author

Published: 26 August 2009 Received: 19 January 2009

Accepted: 26 August 2009
BMC Oral Health 2009, 9:20 doi:10.1186/1472-6831-9-20
This article is available from: http://www.biomedcentral.com/1472-6831/9/20
2009 Humphris et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: The Modified Dental Anxiety Scale (MDAS) is a brief, self-complete questionnaire
consisting of five questions and summed together to produce a total score ranging from 5 to 25. It
has reasonable psychometric properties, low instrumental effects and can be integrated into
everyday dental practice as a clinical aid and screen for dental anxiety. The objectives were to (i)
produce confirmatory evidence of reliability and validity for the MDAS, (ii) provide up-to-date UK
representative norms for the general public to enable clinicians to compare their patients' scores,
(iii) to determine the nature of the relationship between dental anxiety and age.
Methods: Telephone survey of a representative quota sample of 1000 UK adults (>18 years of
age) conducted between 721 April, 2008.
Results: Attrition of potential participants was high in the recruitment process, although bias was
minimal. Estimated proportion of participants with high dental anxiety (cut-off score = 19) was
11.6%. Dental anxiety was four times greater in the youngest age group (1839 yrs) compared to
older participants (60+ yrs), controlling for sex, social class and self-reported dental visiting
behaviour confirming previous developed-world reports.
Conclusion: The scale's psychometrics is supportive for the routine assessment of patient dental
anxiety to compare against a number of major demographic groups categorised by age and sex.
Dental anxiety was high in younger compared to older people.

Background ioural science the simple explanation is insufficient to

Dental anxiety remains a barrier to dental care for a con- explain complex human psychological processes.
sistent proportion of the population [1]. This is disap-
pointing as improvements in oral health over the past One aid to explaining, identifying and reducing dental
three decades have reduced restorative treatment in many anxiety is a good measure of the condition that can be
developed countries. A reduction in dental anxiety levels used in clinical and research settings. Clinicians need to
had been expected as anxiety is related to experience of diagnose the condition and evaluate strategies to reduce
invasive treatment procedures. As very often in behav- it. In interpreting trends and making comparisons,

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researchers need to attend carefully to measurement ically [6] to indicate high dental anxiety that may require
issues. special attention by dental personnel. The measure has
been used in research studies and helped to contribute to
Several methods of assessment have been used. For exam- our knowledge of this important dental related psycho-
ple, the UK Adult Dental Health Survey contained a ques- logical construct. It is one of a number of instruments that
tion about nervousness about visiting the dentist [2]. The have been designed to help study the properties of this
reports are difficult to interpret as the measurement prop- unpleasant feeling [4]. As previously stated, the scale is
erties of this item have not been investigated. Conversely, based on the original Corah's Dental Anxiety Scale
measures based on the Dental Fear Survey [3] consist of (CDAS) [15] for which conversion tables have been pub-
many questions and are more suitable for intensive lished to compare values between the two instruments
research purposes than routine clinical use [4]. Other [16] The MDAS has been translated into a number of
measures are based on Corah's Dental Anxiety Scale world languages, many of which have published psycho-
(CDAS) [2]. The CDAS unfortunately does not enquire metrics (Spanish [17], Turkish [18], Greek [19], Chinese
about local anaesthetic injection, which is a focus for [20]).
some patients' anxiety [5].
A number of reports have presented data of UK samples
Psychometric details for another dental anxiety measure, against which clinicians may compare the scores of their
the Modified Dental Anxiety Scale (MDAS) are available patients [11-13]. However, as these samples may not have
for the UK [6]. This measure, modelled on the original been representative, new data representing UK norms
CDAS, includes a question on local anaesthesia. The orig- would provide a valuable comparator for patient assess-
inal data for this modified scale were published in 1995 ments. Further, researchers or clinicians may benefit from
and some improvements in oral health may have access to percentiles tabulated across major demographic
occurred. Hence a possible outcome is less invasive dental groups to enhance comparison. The advantage of percen-
treatment (e.g. regional improvement in Northeast Eng- tiles is that they can identify the rarity of a patient's score,
land) [7]. In addition, the original norms included a vari- and hence provide information supplementary to being
ety of samples including participants from student above or below a cut-off [21]. Hence the aims of this
groups, various dental services including general and paper were threefold: first, to confirm the factorial validity
industrial dental practice. No large sample was presented of the MDAS and present a precise reliability estimate; sec-
from the general public. A new survey was considered ond, to report a set of norms for the public within the UK
appropriate to update the norms and provide a more com- for clinicians to utilise for comparison with their patients'
prehensive picture for a large sample of the general public scores; and lastly, to determine the nature of the relation-
as this would be instructive for researchers and clinicians. ship between dental anxiety and age.
An additional question to address was whether younger
people have lower anxiety levels than their older counter- Methods
parts. The original set of norms in the UK demonstrated Design
very similar anxiety levels in the first 4 decades of adult A telephone survey was undertaken between 721 April
life. Some reports have indicated that younger adults may 2008 by a market research company (GfkNOP) using a
show lower dental anxiety than their more middle aged structured interview of a representative quota sample (n =
counterparts [6,8]. Such an effect, if repeated in the UK 1000) of UK adults (18 years and over).
public, might suggest that improved oral health and fewer
treatment interventions may be reflected in the UK pub- Sampling
lic's perception of dental care. Potential participants were telephoned using random
dialling in postcodes to obtain a sample that was repre-
The Modified Dental Anxiety Scale is a brief, 5 item ques- sentative of the Office for National Statistics mid 2005
tionnaire with a consistent answering scheme for each population estimates for the 4 individual countries in the
item ranging from 'not anxious' to 'extremely anxious' [6]. UK. To achieve a quota sample of 1000 UK adults, 6937
It is summed together to construct a Likert scale with a unique telephone numbers were called. Of the numbers
minimum score of 5 and a maximum of 25. It is the most called, 1704 were called back as they were either busy or
frequently used dental anxiety questionnaire in the UK [9] engaged (n = 466) or the participant requested the inter-
and does not increase patient fears when completed view take place at a different time (n = 1238). Only 91
[10,11]. Existing data suggest that completion of the ques- calls resulted in no contact being made (due to wrong
tionnaire can significantly reduce state anxiety in the prac- numbers, no answer after a number of call attempts, or
tice setting [12]. It has good psychometric properties, is the number being out of service). Of those contacted,
relatively quick to complete and scoring is easy [13,14]. A 5828 declined to participate and a further 18 stopped the
cut-off value of 19 and above has been determined empir- interview providing a response rate of 14%.

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Measures Results
The MDAS asks participants to rate their emotional reac- The survey completion was excellent with no missing val-
tion to the prospect of a dental visit the day previous, then ues for the MDAS questionnaire. More than 99% of par-
when in the waiting room, receipt of drilling, scaling and ticipants supplied their age and social class. One person
a local anaesthetic injection. Precoded responses range declined to estimate past dental visiting behaviour and 18
from 'not anxious' (scoring 1) to 'extremely anxious' did not provide information about their educational
(scoring 5). Reliability of the English language version of background (see Table 1). The survey sampling was suc-
the MDAS is good (internal consistency = 0.89; test-retest cessful in retrieving participants from all adult age groups
= 0.82). The scale can be downloaded: http://medine.san- and genders. 491 or 51% of the sample were female
drews.ac.uk/supplemental/humphris/dentalAnxiety.htm. reflecting closely the UK proportion. Similarly, age groups
18 to 34 years, 35 to 54 years and 55 years plus matched
Procedure UK proportions of 32%, 34% and 34% respectively.
Potential participants were telephoned out of normal Somewhat more non-manual participants were collected,
working hours. The subject matter, purpose and the likely 59% compared with the UK percentage of 49%.
duration of the survey were explained. Potential partici-
pants were informed that they could decline involvement Table 1: Frequency breakdown and N size for participant sample
in the survey at any stage during or after the interview. including MDAS means (SD) and percent 19
Having been asked about demographic data, participants N % Mean SD % 19
were asked the 5 questions of the MDAS. In addition,
other questions were asked on the use of dental therapists, Total 963 100 10.39 5.46 11.6
the findings of which will be reported elsewhere.
Sex
Statistical analysis Male 472 49.0 9.22 4.94 8.3
Data were analysed using SPSS v16, and reliability analy- Female 491 51.0 11.52 5.69 14.9
sis conducted with FACTOR [22]. The scale was factor ana-
Age (years)
lysed (principal factor method) and Horn's parallel 1829 189 19.6 11.62 5.44 14.3
analysis was run to determine the factorial structure [23]. 3039 179 18.6 11.61 5.88 17.3
Confirmatory analyses were also completed using 4049 170 17.7 10.28 5.34 12.4
AMOS17 [24]. Means and standard deviations were calcu- 5059 175 18.2 10.29 5.33 10.3
lated across the major demographic factors and self- 6069 119 12.4 10.03 5.27 8.4
reported visiting. A set of percentiles was prepared across 70+ 125 13.0 7.64 4.29 4.0
Refused 6 0.6 6.33 1.51 0.0
gender and major age groups. A threshold of 19 and above
was adopted, as the level for which is it likely that a dental Visiting the dentist
practitioner would consider using additional approaches Regular 686 71.2 9.94 5.12 9.3
to manage the patient such as relaxation, systematic Occasional check up 134 13.9 10.75 5.38 12.7
desensitisation or pharmacological adjunct. Item frequen- When in pain/or trouble 90 9.3 12.39 6.59 22.2
cies were inspected for male and female samples and the Never been 52 5.4 12.17 6.73 21.2
ratings examined across samples to determine if individu- Refused 1 0.1
als differ by anticipatory (i.e. contemplating a visit to the
Education
dentist the next day and sitting in the waiting room) and No school 30 3.1 10.37 5.92 16.7
treatment related items using the Wilcoxon Ranks Sign Secondary 97 10.1 10.45 5.37 10.3
test. The proportion of individuals who scored 19 and Secondary with qualifications 239 24.8 10.54 5.84 14.2
above was calculated across the demographic and behav- College A levels 185 19.2 10.10 5.41 11.4
ioural variables. Cross tabulations were performed with Technical GNVQ 84 8.7 10.32 5.74 15.5
categorical variables. Multiple logistic regression was University degree 151 15.7 10.28 5.01 7.9
University post grad degree 158 16.4 10.42 5.10 8.2
employed to establish the independent association of
DK/Refused 19 1.9 12.16 6.41 21
demographic factors (gender, age, educational level,
social class and self-reported dental visiting) on the Social class
dichotomous classification of high (19) and moderate to A 44 4.6 10.48 6.41 15.9
low dental anxiety (18). Significance level was set at the B 180 18.7 10.14 5.1 7.8
conventional 5%. C1 342 35.5 10.15 5.07 9.1
C2 159 16.5 11.14 5.59 17.0
D 82 8.5 11.91 5.88 17.1
Ethical approval for the study was granted by the Univer-
E 148 15.4 9.76 5.94 12.8
sity of Sheffield, UK. Refused 8 0.8 7.38 3.02 0

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To satisfy the first study objective we confirmed the psy- tabulation of educational level appeared not to be associ-
chometric properties of the MDAS. An exploratory factor ated with the categorisation of those into the two dental
analysis using parallel bootstrapping to derive simulated anxiety groups (high versus moderate or low). However,
eigenvalues from random samples for comparing with the this was somewhat misleading as there were 7 categories
observed data was conducted. The Kaiser-Meyer-Olkin of educational level which were not ranked into a clear
test (indicates if sufficient common variance exists to order. For example the 'technical GNVQ' qualification
merit factor analysis) gave a satisfactory high value of was regarded as a vocational award as opposed to achiev-
0.842. The factor analysis demonstrated a clear unity fac- ing a high academic standard. For the purposes of the
tor structure (eigenvalue for first factor = 3.69, which is multiple logistic regression analysis this factor was dichot-
equivalent to three times the average amount of variance omised into those participants with a university education
contained within this factor as the rest of the covariance as opposed to those without. Similarly the social classifi-
matrix, and eigenvalue for second factor = 0.51) demon- cation variable was split into manual and non-manual
strating that the scale can be considered uni-dimensional categories.
for practical purposes. Random eigenvalues derived from
the bootstrapping procedure showed that 2 factors would The individual item frequencies (see Table 2) showed that
have been selected (eigenvalues of 1.13 and 1.06) if the the majority of men were 'not anxious' on anticipatory
popular unity criteria for setting the number of factors had events (visiting the dentist tomorrow and sitting in wait-
been adopted. The single factor contained 93% of the ing room) and scale and polish compared with receiving
explained variance. This result was supported partially by the drill and local anaesthetic injection. The majority of
testing the model constrained to a single latent factor. Fit women however were at least 'slightly anxious' with all
statistics showed excellent correspondence between the items in the questionnaire (with exception of 'scale and
model and raw data with just 3 error covariances relaxed polish'). The replies of each sex to each item was tested
(chi square = 3.89; df = 2; p = .14; CFI = .999, TLI = .997, against the other items in the scale by the Wilcoxon Ranks
RMSEA = .031). The internal consistency coefficient of the Sum Test. All items were rated significantly different from
scale was excellent (0.957, 95%CI 0.953, 0.961). each other (p < .001) with the exception of the two antic-
ipatory items (Items 1 and 2) which displayed similar rat-
The proportion of participants at or above the threshold ings for both men (p = .056) and women (p = .272).
of 19 on the MDAS showed considerable range across
many of the demographic variables and past dental visit- The second objective of the study was completed by calcu-
ing patterns. This variation is explored in more detail in lation of percentile norms for MDAS scores for the UK
the multiple logistic regression analysis below. The cross- population by age and gender (Table 3). To aid interpre-

Table 2: Item frequency breakdown of MDAS across male and female samples

MALE
Question Visit Tomorrow Waiting Room Use of Drill Scale and Polish Injection
N % N % N % N % N %

not anxious 283 60 270 57 188 40 346 73 212 45

slightly anxious 103 22 108 23 132 28 79 17 136 29
fairly anxious 31 7 41 9 59 13 19 4 56 12
very anxious 32 7 29 6 52 11 13 3 40 8
extremely anxious 23 5 24 5 41 9 15 3 28 6

Base N (%) 472 100 472 100 472 100 472 100 472 100

FEMALE
Question Visit Tomorrow Waiting Room Use of Drill Scale and Polish Injection
N % N % N % N % N %

not anxious 217 44 209 43 120 24 307 63 135 27

slightly anxious 108 22 122 25 124 25 88 18 135 27
fairly anxious 71 14 51 10 63 13 49 10 86 18
very anxious 45 9 60 12 94 19 24 5 71 14
extremely anxious 50 10 49 10 90 18 23 5 64 13

Base N (%) 491 100 491 100 491 100 491 100 491 100

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Table 3: Means, medians (SDs) and percentiles for total MDAS scores broken down by sex and age group

M 1839 M 4059 M 60+ F 1839 F 4059 F 60+

N 161 185 122 207 160 122

Mean 10.84 8.99 7.52 12.21 11.79 10.09
Median 9 8 6 12 11 9
SD 5.63 4.57 3.81 5.61 5.74 5.57
Percentiles Percentiles
5 5 5 5 5 5 5 5
10 5 5 5 5 5 5 10
15 5 5 5 6 5 5 15
20 6 5 5 6 6 5 20
25 6 5 5 7 7 5 25
30 7 6 5 8 7 6 30
35 7 6 5 9 8 6 35
40 8 7 5 9 9 7 40
45 9 7 5 11 10 8 45
50 9 8 6 12 11 9 50
55 10 8 6 13 11 9 55
60 11 9 7 14 12 9 60
65 12 9 7 14 13 10 65
70 13 10 8 16 15 11 70
75 14 11 9 17 16 14 75
80 16 11 10 17 17 15 80
85 18 13 12 19 19 16 85
90 19 17 13 20 21 19 90
91 20 18 13 21 22 19 91
92 21 18 13 21 22 20 92
93 22 19 14 21 22 21 93
94 22 19 16 22 22 22 94
95 23 20 16 22 22 24 95
96 23 20 17 23 23 25 96
97 23 20 19 23 24 25 97
98 25 21 21 24 25 25 98
99 25 24 23 25 25 25 99

Note: bold type indicates all values 19

tation of the table the values of the MDAS at 19 and above Table 4) and confirmed that high dental anxiety was more
have been formatted in bold type at the appropriate per- common among younger adults independent of sex, occu-
centile points. Three broad age groups are presented. The pation and education. The latter three factors were rela-
precision of the location of the cut-off value against the tively of less explanatory value than age of respondent.
percentile scale was considered to be important. Such pre- Age was the strongest predictor of those with high anxiety
cision would have been compromised had all 6 age ( 19 score) with participants aged 1839 over four times
groups been listed. From inspection of the cut-offs at each more likely to be dentally anxious than those 60 years or
age group across the sexes there appeared to be an interac- older. Middle aged participants (4059 years) were 3
tion between age group and gender. Almost 15% of times more likely to score at or over the cut-off.
women scored above the cut-off for the MDAS whereas
only 8% of men scored this highly. On further inspection Discussion
of the tables and single items it was clear that approxi- These data support the performance of the MDAS as a
mately twice the number of women (18 and 13%, respec- measure of dental anxiety. The internal consistency was
tively) compared with men (9 and 6%, respectively) were very high and the items appeared to describe a uni-dimen-
extremely anxious about drilling and local anaesthetic sional construct which we would understand as providing
injection. Similarly, 10% of women stated that they were a dimension of dental anxiety ranging from low to high.
extremely anxious about anticipating a dental visit the More sophisticated methods are available [25] to tease out
next day and sitting in the waiting room compared with discrepancies to this measurement model, however for
5% of men. practical purposes the user will find that the responses
they receive from individual participants are easily inter-
The final objective of the study was achieved from the pretable.
results of the multiple logistic regression analysis (see

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Table 4: Logistic regression to predict those at cut-off of 19 or above on the MDAS with variables: age group, sex, social class,
education and self reported visiting to the dentist entered simultaneously

Variable Odds Ratio1 95% CI p value

Lower Upper

Age group
60+ years2 1.00 0.0002
1839 years 4.14 2.12 8.07 0.0001
4059 years 3.01 1.51 5.99 0.0017

Sex
Male2 1.00
Female 2.09 1.35 3.24 0.0010

Social class
Non-manual2 1.00
Manual 1.80 1.16 2.80 0.0088

Education
University qualification2 1.00
No university qualification 1.77 1.06 2.96 0.0288

Self-reported visiting to the dentist

Regular2 1.00
Irregular 2.26 1.48 3.46 0.0002

1 Adjusted for the other variables in the table

2 Reference category

This is the first report providing normative data of a rep- tist that about half of the people his age score lower than
resentative sample of the UK general population. The level him, and by implication, half score higher.
of high dental anxiety in the sample was 11% and is com-
parable to other reports from local or regional community The total scores for the MDAS varied by sex and age group
surveys [6,11]. A large representative UK survey (N = but unlike the higher category of dental anxiety (e.g.
1800) using Corah's Dental Anxiety Scale has been extremely anxious or above the cut-off value), the interac-
reported which showed that 11% of their sample showed tion of age and sex was not significant. That is, it would
high dental anxiety (15) [26]. Caution should be taken appear that at more extreme levels of dental anxiety the
when comparing studies that use different measures and effect of age and gender interacted so that in older age
cut-off values. For example, two 'conventional' cut-off val- groups women were more dentally anxious than men and
ues (13 and 15) are often used for data collected from that these differences were stronger than at the lowest age
Corah's scale (see for examples [27] and [26]). The cut-off group. The comparison of results between averages and
of 19 was selected for the MDAS previously on empirical proportions scoring at a clinically relevant cut-off across
grounds, and provides greater confidence in the interpre- the factors of age and gender, was interesting and alerts
tation of the proportion that score at or above this point. the researcher and clinician to focus on the purpose and
use of scores obtained from an instrument such as the
These figures are also reflected in the overall scores pre- MDAS. Caution is required when considering patients in
sented in the form of percentiles. The percentile at which higher scoring groups as previously mentioned. The valid-
men reach the 19 cut-off point was 90% in younger men ity of the cut-off, although empirically determined,
(18 39 years) whereas in women this point was reached requires additional support. The relatively small error
at the 85th percentile. However, an interesting interaction contained in the measure should not be ignored and
of gender with age was apparent, reflected in the much should indicate to the practitioner that repeated assess-
higher percentile (97th) in the oldest male age group (60+ ment at a later date would be prudent. A discussion with
years) compared with female counterparts (90th). A male patients about their feelings associated with dental visit-
patient aged 60+ years who scored 19 would be part of ing would also assist in the assessment process, especially
just 3% of the general population with the same or higher with those with high scores.
score whereas the comparable female would be associated
with as many as 10% of the public. Moreover, a 25 year The population norms produced by this survey for the
old male with a score of 9 could be informed by the den- MDAS have merit as they are recently produced and are

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likely to be more representative. The original norms pub- staff may need to engage more with their patients, proba-
lished in 1995 comprised of four groups of participants bly at the young end of the age spectrum to develop resil-
obtained in the first 2 years of that decade. They included ience. The employment of active and sensitive
industrial dental service and general practice service users, communication skills may enhance this process [30].
members of the community visiting their general medical
practitioner (GMP) and mothers attending the commu- Potential limitations of this study should be considered.
nity dental service with their child. The closest compara- Every effort was made by the market research company to
tive group was the GMP visitors as they will comprise of ensure a representative sample. The original spreadsheets
participants who do not visit the dentist a feature not of the age, gender and social status breakdown showed
apparent in the other 3 original groups. The mean (SD) that the discrepancy between what the survey aimed to
levels of the current study (n = 963) and the 1995 'com- collect to attain representativeness and what was actually
munity' group (n = 525) were 10.36 (5.36) and 10.39 collected was found to be similar. Admittedly there was a
(5.46) respectively. These showed remarkable similarity (t minor over-representation of ABC respondents. Residen-
= 0.10, df = 1486, p = .54). Another interesting compari- tial location however was a good fit. The strength of asso-
son was to inspect the percentages of participants who ciation between social class and dental anxiety was one of
rated their anxiety as 'extremely anxious'. These data were the weakest factors entered into the logistic regression
available for both the total (genders combined) samples (together with education). Hence a weighting procedure
in the original (page 146, table four) and current surveys. to the analysis was not considered to be warranted due to
The level of the rating was identical for the anticipatory the increased complexity of introducing such a procedure.
items (1 and 2) however the percentage who rated the The response rate of 14% was admittedly low although as
injection as extremely anxious was 14.6% in 1993 and argued immediately above we believe the potential bias
only 9.5% in 2008. The mean dental anxiety scores for was minimal. Other authors using telephone survey tech-
those aged 60 and above were higher in males in the cur- niques also experienced similar problems (with an 18.5%
rent survey compared to the original community sample response rate) and use identical arguments to our own to
(page 147; table five, males: mean = 7.52 (3.81) n = 122 support the veracity of the data set [28]. However, a risk of
versus 6.52 (2.34) n = 50; t = 2.17, df = 170, p = .016), sampling bias exists with telephone survey methods if
whereas females showed a smaller increase in the recent response rates vary in different groups within a popula-
survey compared to the original, and the difference was tion. For example, some may not have a landline tele-
not significant: 10.09 (5.57) n = 122 versus 9.23 (5.25) n phone and may only use mobile telephones. Although the
= 71; t = 1.07, df = 191, p = .146). There is partial support impact of such potential bias is unknown, other methods
therefore for Locker's suggestion [28] that the 5059 year are also prone to response bias for similar reasons. For
old cohort 'will carry their relatively high levels of dental example, postal surveys can lead to over representation of
anxiety into old age' [29]. This effect appears to be shown the views of white participants with higher incomes and
in males only. These comparisons are tentative at best educational attainment [31]. Telephone interviews have
however, and await more extensive and organised data been used in national dental surveys [32] and remain an
collection from longitudinal studies. important method for public health and social surveys
seeking populations' views, particularly in North America
The major demographic variables were found to relate [33-35].
strongly with dental anxiety as shown in the multiple
logistic regression analysis. Dental anxiety has been Conclusion
reported frequently in previous studies to vary with sex, This new dataset has determined that the MDAS showed
age, education and social class. Of interest in particular for high reliability and excellent completion of scale items.
this study was the relationship of age group with the cate- No support was found for reduced dental anxiety in
gorisation of high versus low/moderate dental anxiety. The younger age groups. The set of norms produced will be
benefit of conducting the multiple logistic regression was useful for dentists and researchers when interpreting indi-
that the effects of education and social class were removed viduals' expression of dental anxiety through the MDAS
to allow a focus on the relationship of dental anxiety by questionnaire.
age. No evidence could be found for a reduction of the
proportion of participants with high dental anxiety in the Competing interests
youngest age group. Rather the likelihood of being highly The authors declare that they have no competing interests.
dental anxious compared to those 60 years of age or more
was four times greater. This finding supports the view that Authors' contributions
dental anxiety is relatively stable as a construct regardless GH, TD and PR conceived and designed the study. GH
of changes to treatment delivery. An interesting possibility analysed the data, drafted the article and subsequent ver-
may be that to achieve reductions in dental anxiety dental sions. TD and PR coordinated the data collection via the

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survey organization, contributed to the manuscript, and 22. Lorenzo-Seva U, Ferrando P: FACTOR: A computer program to
fit the exploratory factor analysis model. Behavioral Research
edited all drafts. All authors read and approved the final Methods, Instruments and Computers 2006, 38:88-91.
manuscript. 23. Horn J: A rationale and test for the number of factors in fac-
tor analysis. Psychometrika 1965, 30:179-185.
24. Arbuckle J: Amos 17 User's Guide. In 17.0 version Spring House:
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Economides N, Kotsanos N: Psychometric properties of Greek scientist can read your work free of charge
versions of the Modified Corah Dental Anxiety Scale "BioMed Central will be the most significant development for
(MDAS) and the Dental Fear Survey (DFS). BMC Oral Health disseminating the results of biomedical researc h in our lifetime."
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20. Yuan S, Freeman R, Lahti S, Lloyd-Williams F, Humphris G: Some Sir Paul Nurse, Cancer Research UK
psychometric properties of the Chinese version of the Mod- Your research papers will be:
ified Dental Anxiety Scale with cross validation. Health and
Quality of Life Outcomes 2008, 6:22. available free of charge to the entire biomedical community
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norms and accompanying interval estimates for self-report cited in PubMed and archived on PubMed Central
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