presents a comparison of the sample characteristics with those of the Australian population as derived from the Australian census in 2001. There was good similarity between population characteristics and those of the sample.
In response to the single-item DAQ, 67.7% of participants responded 'Not at all', 15.1% responded 'A little', 5.2% said 'Yes, quite', and 11.9% stated 'Yes, very'. A number of socio-demographic differences were observed between dental fear groups (Table 2).

Table 2

Socio-demographic and dental characteristics by dental fear

Not afraid A little afraid Quite afraid Very afraid   n % n % n % n % Dentate status***                       Dentate 3,482 90.3 826 96.2 295 99.0 648 95.3       Edentulous 375 9.7 33 3.8 3 1.0 32 4.7 Sex***                       Male 2,024 52.4 332 38.6 124 41.6 218 32.1       Female 1,837 47.6 529 61.4 174 58.4 462 67.9 Age***                       16–24 years 633 16.4 160 18.6 45 15.2 61 9.0       25–39 years 1,117 28.9 269 31.2 90 30.3 191 28.1       40–64 years 1,417 36.7 341 39.6 135 45.5 349 51.3       65+ years 695 18.0 92 10.7 27 9.1 79 11.6 Country of birth                       Australia 2,958 76.6 647 75.1 231 77.5 514 75.6       Other 903 23.4 214 24.9 67 22.5 165 24.3 Language spoken at home                       LOTE 461 11.9 121 14.1 33 11.1 75 11.0       English 3,401 88.1 740 85.9 265 88.9 604 89.0 Employment*                       Full-time 1,577 42.9 365 44.4 135 47.4 261 39.0       Part-time 673 18.3 148 18.0 64 22.5 145 21.6       Not employed 1,422 38.7 309 37.6 86 30.2 264 39.3 Annual household income**                       Less than $20,000 824 24.3 151 19.8 52 20.2 141 23.5       $20,001 – $50,000 1,111 32.8 236 30.9 97 37.7 239 39.8       $50,001 – $80,000 783 23.1 210 27.5 62 24.1 123 20.5       Greater than $80,000 672 19.8 166 21.8 46 17.9 97 16.2 Residential remoteness                       Highly accessible 2,586 67.2 590 68.7 204 69.2 455 67.5       Accessible 799 20.8 179 20.8 66 22.4 151 22.4       Moderately accessible 401 10.4 83 9.7 22 7.5 55 8.2       Remote 50 1.3 5 0.6 3 1.0 8 1.2       Very remote 10 0.3 2 0.2 0 0.0 5 0.7

* χ2 < 0.05, ** χ2 < 0.01, *** χ2 < 0.001 Note: Dentate refers to at least one natural tooth present in the mouth

Higher dental fear was associated with being dentate, female, having part-time employment or being unemployed, and having an annual household income of between $20,000 and $50,000 per year. Dental fear was also associated with age, increasing across age groups up to 46–64-year-olds but then decreasing among those aged 65+ years old. The association between fear and country of birth and speaking a language other than English at home was not statistically significant. Similarly, residential remoteness as measured by the Accessibility/Remoteness Index of Australia (ARIA) and based on road distance to service centers was not significantly related to dental fear. Dental fear was associated with having had a longer time since the last dental visit and a greater average time between visits. While 56.5% of people with no dental fear last visited the dentist in the previous 12 months, 46.2% of people who were very afraid of visiting the dentist reported last visiting within the previous year. Looking at average visiting frequency, 44.1% of people who rated themselves as very afraid visited the dentist less than once every two years on average compared to approximately 30% of individuals with no dental fear. In terms of future visiting patterns a similar trend was observed, with 76.9% of people who were very afraid expecting to make a dental visit in the next year, compared to 66.7% of people with no dental fear. In relation to when people expected to make their next dental visit, perhaps the most striking difference was that 27.6% of people who were very afraid of the dentist expected to make their next visit only when they experienced pain or a problem, compared to less than 17% of people with less dental fear. Almost 17% of the no dental fear group had an existing appointment to see a dentist compared to only 11.4% of the very afraid group. People who were very afraid of visiting the dentist had significantly more teeth missing than did people with less extreme dental fear (Table 4).

Table 4

Mean number of teeth missing due to dental caries by dental fear

Maxillary arch Mandibular arch Afraid of the dentist Mean SD Mean SD Not at all 2.73a 4.02 2.11a 2.78 A little 2.60b 3.68 1.94b 2.39 Yes, quite 3.01 4.15 1.89c 2.39 Yes, very 3.61a,b 4.66 2.61a,b,c 2.78   F = 9.76, p < 0.001 F = 9.01, p < 0.001

Note: Superscripts indicates significant Scheffe post-hoc differences, p < 0.05.

Confining analyses to the maxillary arch, people with the most dental fear had significantly more missing teeth than people with either no dental fear or a little dental fear. Similarly, those people who were very afraid of going to the dentist had significantly more missing teeth in the mandibular arch than those people who were not afraid, were a little afraid or were quite afraid of going to the dentist. Higher self-rated dental fear was associated with significantly greater perceived need for fillings, tooth extraction, a scale and clean, a check-up, gum treatment, a dental crown or bridge and other treatment (Figure 2).

Perceived treatment needs by dental fear

There was a linear relationship between dental fear and perceived need for a filling, an extraction and gum treatment. The distribution of responses to questions assessing the social impact of problems with the teeth, mouth or dentures of people with different levels of dental fear are shown in Figure 3.

Psychosocial impacts of problems with teeth, mouth, or dentures during the previous 12 months by dental fear

Dental fear was associated with a higher prevalence of toothache (χ2 = 64.35, p = 0.001), more discomfort with the appearance of teeth, mouth or dentures (χ2 = 184.16, p < 0.001), more frequent food avoidance due to dental problems (χ2 = 108.11, p < 0.001), finding life less satisfying because of dental problems (χ2 = 127.12, p < 0.001) and more trouble sleeping as a result of dental problems (χ2 = 78.15, p < 0.001). Not only did people with very high dental fear report these impacts more often than did people with lower fear, but the ratings were more extreme with more people with very high fear stating that these social impacts occurred 'very often' than did people with less or no dental fear. Participants made a global assessment of their oral health in response to the question "How would you rate your own dental health?" Just over 45% of people with no dental fear rated their dental health as being excellent or very good compared to 30.9% of people who were very afraid of going to the dentist (Figure 4). 

Self-rating of dental health by dental fear

Conversely, people with the most dental fear were more likely to rate their dental health as average, poor or very poor (36.4%) in contrast to people who were not afraid, a little afraid or quite afraid (17.7%, 22.2% and 28.3% respectively). The association between dental fear and self-rated oral health was statistically significant, χ2 = 178.95, p < 0.001.

Some 61.3% of people who were very afraid of going to the dentist reported that the reason for their most recent visit in the last 12 months was for a problem, compared to 47.2% of people with no fear, 53.5% of people with a little fear and 59.4% of people who were quite afraid of going to the dentist (χ2 = 31.09, p < 0.001). In addition, 67.3% of people with very high dental fear reported that their usual reason for a dental visit was for a problem compared with only 44.9% of people with no dental fear, 47.1% with a little fear and 45.8% who were quite afraid (χ2 = 121.03, p < 0.001). Of those people who usually visited the dentist for a problem 72.3% of people who were very afraid of going to the dentist stated that the problem was usually for the relief of pain, compared to 54.7% of people with no dental fear, 67.2% with a little fear and 61.7% who were quite afraid (χ2 = 57.72, p < 0.001).

Given that dental fear showed a relationship with delayed visiting patterns, poorer dental health and symptom-driven treatment, justification was provided for examining the cyclical process that is proposed as characterising the maintenance of dental fear. Specifically, we examined the relationship between fear and delayed visiting, the relationship between delayed visiting and dental problems, the relationship between dental problems and symptom-driven treatment, and finally the relationship between symptom-driven treatment and fear. Complete information on delayed visiting, dental problems, and usual reason for visiting was available for the 3,615 non afraid, 826 a little afraid, 271 quite afraid and 612 very afraid individuals.

People with high dental fear were significantly more likely to have a delayed visiting pattern, with a significantly higher percentage last visiting a dentist at intervals of greater than 2 years (43.9%) in comparison to people who were not, a little or quite afraid (29.1%, 26.5% and 27.7% respectively), χ2 = 62.65, p < 0.001. In turn, those people with a longer time since their last dental visit had significantly more dental problems. People who last visited the dentist more than two years previously were significantly (Chi-square tests, p < 0.001) more likely to perceive themselves as needing a filling (39.4%), an extraction (18.6%) or gum treatment (12.6%) in contrast to people who had last visited within 2 years (23.7%, 7.3%, and 7.9% respectively). Of those people who perceived themselves as in need of dental treatment, determined here by anybody who responded that they needed either a filling, an extraction or gum treatment, 61.1% usually visited the dentist for an emergency treatment in comparison to 36.8% of people without a perceived need for a filling, extraction or gum treatment, χ2 = 330.58, p < 0.001. Finally, a significantly greater percentage of people who usually visit the dentist for an emergency were very afraid of going to the dentist (16.3%), compared to people who normally visit for a check-up (7.3%), χ2 = 106.02, p < 0.001. A graphical presentation of the concept of a vicious cycle for the four fear groups is shown in Figure 5.

Following the path of the vicious cycle by categories of dental fear

The figure shows the number and percentage of people in each fear group, after each component of the vicious cycle, who still fit the profile at that given point in the cycle. Overall, 179 people or 29.2% of those who were very afraid of going to the dentist fitted the profile of having delayed dental visiting, dental problems, and symptom-driven treatment seeking. This can be contrasted to the 11.6% of the group with no dental fear who exhibited the same characteristics.

Because dental fear was shown to vary by individual characteristics (see Table 2),

a multivariate logistic regression was carried out to see if the difference between dental fear groups in fitting a vicious cycle profile was accounted for merely by differences in socio-demographic and dentate status variables between groups with differing levels of dental fear. The odds ratio of very fearful individuals having delayed dental visiting, dental problems, and symptom-driven treatment seeking was 3.33 (95% confidence interval 2.67–4.15) that for people without dental fear (Table 5).

This effect for dental fear was statistically significant even though sex, dentate status, employment status and annual household income exhibited significant associations with fitting a profile consistent with being part of a vicious cycle. The odds ratios for people who were a little afraid or quite afraid of going to the dentist (ORs = 1.24 and 1.40 respectively) were in the expected direction but not statistically significant.

© 2007 Armfield 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.

published: 21 January 2008