....................

FEATURE ARTICLE
................................................

Joseph M. Holtzman, PhD, Robert G. Berg, DDS, MPH, MS, Jonathan Mann, DMD, MSc,
Douglas 6. Berkey, DMD, MPH, MS

The relationship of age and gender to fear and anxiety

in response to dental care
ental fear and anxiety have Chinese.14Peretz and Zadik, compar-
The apparent association in the
published literature of gender and
been repeatedly identified as ing the levels of dental fear and anxi-
important factors in the delay ety among three age groups of par-
age with dental fear and anxiety is
and avoidance of dental ~ a r e . lGender
-~ ents in an Israeli kibbutz population,
far from consistent or universal. A
random, agestratified telephone sur-
and age have often shown an associa- reported that mothers in the middle
vey of 398 adults was performed in a
tion with dental fear and anxiety, age group reported the highest dental
US metropolltan area: Denver,
with fear and anxiety more frequent- fear and anxiety scores, while among
ly reported in females than in males, fathers, the lowest age group report-
Colorado. Information collected
and age inversely related to levels of ed the highest scores.15Similarly,
included Kleinknecht’s Dental Fear
fear and anxiety.6-10However, the Hakeberg, Berggren, and Carlsson, in
Survey (DFS). In additlon to total
apparent association of gender and comparing the distribution of high
DFS scores, values were also calcu-
age with dental fear and anxiety is far fear and anxiety by age, report that
lated for the sums of the five DFS .
from consistent or universal. A num- 20-39-year-old subjects had a signifi-
physlologic response items (PATRE-
ber of recent studies have raised cantly higher percentage reporting
SP) and 12 DFS fear-produclngstim-
questions regarding the strength and high fear and anxiety than younger
ulus Items (DENTSTIM). Tests for
direction of these associations. or older age g r 0 ~ p s . l ~
reliabillty of these three scales were
performed (alpha = 0.804 to 0.936).
For example, Locker and Liddell, In this study, we revisit the rela-
in a study of correlates of dental anxi- tionships of dental fear and anxiety
In this sample population, significant
age and gender differences were
ety among adults age 50 and over, with age and gender. Further, we
noted. In general, fear and anxiety
reported that age was the only demo- examine differences in what age and
decreased in importance with
graphic factor associated with dental gender groups identdy as distressing
increased respondent age, with the
anxiety, with dental anxiety less stimuli in the dental environment.
largest dlfference noted between the
prevalent among older adults than in Clarifying these relationships would
the younger population.” Locker and appear to be a logical step toward the
40-50 and 60-69 age groups.
Liddell failed to find sigruficantdif- development and/or refinement of
Increased fear and anxiety were
most apparent among younger
ferences in dental anxiety by gender. age- and gender-relevant approaches
However, Moore et al. found, in a to the reduction of fear and anxiety in
females (20-30 and 40-50) as com-
pared with older females (60 and
large random sample of Danish the clinical setting.
adults, higher dental anxiety associat-
older). However, among males, the
summary variable for physlologic
ed with female gender, less educa-
tion, and lower income, but not with Methods
response to fear and anxiety did not
age.12In a study of dental fear and Data for this study were collected as
appear to be age-related. Among the
oldest respondents (ages 70+),
anxiety among Japanese-Americans, part of a more comprehensive study
Domoto et al. found that fear and of the influence of oral symptoms on
12.2%did report a “major” response
to muscle tension when in the dental
anxiety did not vary with age.13In a utilization of dental services across
chair. Females reported more fear of
comparative study of dental fear and the lifespan. A detailed description of
some stlmuli associated with dental
anxiety in Danish and Chinese sampling methods and procedures
care (e.g., “feeling the drill In the
adults, Schwarz and Birn found that along with a portion of the data
mouth”) than did males.
women more frequently reported focusing on the utilization behavior
fear and anxiety only among the of seniors has been published else-

82 SCD Speclal Car8 In Dentistry, Yo117 No 3 1967

 where.17However, a brief desciption
of the sampling and data collection
strategy follows.
Data were collected via an age-
stratified quota sample of 398 com-
munity-dwelling adults surveyed by
telephone. The local telephone com-
pany estimated that published list-
ings represented approximately 75%
of all residential telephone customers.
Telephone numbers were randomly
selected from published residential
listings in metropolitan Denver,
Colorado. Subjects were accepted to
fill four study groups of approxi-
mately 100 individuals each: ages 20-
30,40-50,60-69, and 70 or over.
Sampling continued until quotas for
all four groups were reached. Dental
fear data were collected via the 20-
item Kleinknecht Dental Fear Survey
(DFS), widely accepted as a useful
and reliable measure of fear and anxi-
ety.7,1s-20In addition, socio-demo-
graphic characteristics-including
age, gender, ethnicity, education,
employment, and oral health status-
were also collected.
Four broad measures were used to
evaluate fear and anxiety. The most
comprehensive of these is the DFS
score, a sum of responses to all of the
items on the Kleinknecht instrument.
The second summary scale for this
study, the Patient Response Scale
(PATRESP),was produced by adding
scores for the five Kleinknecht ques-
tions pertaining to specific perceived
physiologic responses which the
respondent experienced while receiv-
ing dental services. Categories for
these items were (1)Never, (2) Once
or twice, (3) A few times, (4) Often,
and (5) Nearly every time. A third
summary scale was the Dental
Stimulus Response Scale (DENTSTIM).
This is the sum of responses to the 12
questions on the Kleinknecht instru-
ment which dealt with specific dental
stimuli reported to cause fear or anxi-
ety for respondents. Responses for
stimuli were (1) None, (2) Very little,
(3) Some, (4)A fair amount, and (5) A
great deal. Finally, the fourth mea-
sure (OVERALL)was the simplest:
the final question on the Kleinknecht
instrument. That is, “Overall, how
fearful are you of having dental work
done?” Subjects responded to this
item with the categories noted above
for specific dental stimuli.
Results
Respondent characteristics
Telephone contact with a qualified
subject was made at about 750 house-
holds. Approximately 53% (398)
agreed to participate (characteristics
of individuals who were contacted,
but did not participate, were not
determined). However, telephone
surveys typically exclude individuals
living in institutions, those unable to
afford telephone service, and those
too ill or hard of hearing to carry on a
telephone discussion. Therefore,
these groups were probably under-
represented among repondents. In
this sample, 69% of respondents were
female, 91% were high school gradu-
ates, 65% of those under age 65 were
employed, and 12.9% were totally
edentulous.
Nineteen percent of the sample
had maxillary full dentures, and
about 12%had mandibular full den-
tures. Within the two groups aged 60
and older, 25.8% were totally edentu-
lous. None of the respondents under
age 60 was totally edentulous. Since
previously reported data indicated
significant differences in symptom
perception and response between
dentate and edentate subjects, inde-
pendent of age, the decision was
made to exclude totally edentulous
respondents from the analyses pre-
sented be10w.l~
Across all age groups, 68.5% of the
345 dentate respondents were female.
The highest proportion of females
was in the 60-69 age group (76.5%);
the lowest was in the 20-30 group
(60.6%).The predominant self-report-
ed ethnicity (90.7%) was non-
Hispanic White; 3.2% were Hispanic,
2.6% Native American, 1.2% African-
American, 1.2%Asian-American, and
1.2% ”Other”. Most dentate respon-
dents (93.6%)were high school grad-
uates, and 36.3% were college gradu-
ates. Overall, 49% were employed;
the highest proportion was 77.6% of
those aged 40-50, and the lowest was
SCD Special Care In Dentlstry, Vol17 No 3 1997 83
6.2% of those aged 70 and over.
Summary measures
of fear and anxiety
In order to facilitate certain analyses,
DFS, PATRESP, and DENTSTIM
scores were collapsed into ordinal
classification groups, based on the
means for each scale. Subjects were
assigned to groups designated as
”high“, “medium”, or “low” for each
scale. Cutting points were set so that
one-third of subjects would be
assigned to each group for each scale.
Once groupings were created, the
collapsed scores were treated as cate-
gorical variables for some analyses.
Ranges, means, and standard
deviations for the summary measures
were: DFS (20-99,37.3,16.0), PATRE-
SP (5-25,8.6,4.4), and DENTSTIM
(12-60,23.9,10.9). PATRESP and
DENTSTIM were reasonably correlat-
ed with each other (Pearson correla-
tion coefficient r = 0.65, p < 0.001).
Tests for reliability of DFS, PATRESP,
and DENTSTIM (Cronbach’s alpha)
yielded values of 0.936,0.804, and
0.920 (respectively).
Respondent age was found to be
negatively correlated (p < 0.001) with
scores on the DFS (r = - 0.40)’ PATRESP
(r = - 0.26), and DENTSTlM (r = - 0.42)
scales. Older respondents tended to
report less fear and anxiety (as mea-
sured by these scales) than younger
respondents. When respondents were
categorized by age group (20-30,40-
50,60-69,70 and over) and compared
using either means (simple ANOVA)
or high/medium/low values (Chi-
square) of DFS, PATRESP, and
DENTSTIM, the age-fear/anxiety
relationship was maintained (p <
0.001). The higher the age group, the
lower the fear and anxiety for each of
these variables. When gender differ-
ences in level of fear across age
groups were compared, a significant
difference was found for DENSTJM.
Across gender (t tests for independent
samples), the means for DENTSTIM
were significantlyhigher for females
(p = 0.048). However, no statistically
significant differences were observed
for DFS or PATRESP scores.
Linear regression analyses for pos-
sible effects of age group, gender,
Table 1.Linear regression models.”
Variable Beta Significance
DFS
70+ -0.3916 0.0001
60-69 -0.3174 0.0001
Female 0.1558 0.0017
PATRESP
70+ -0.2587 0.0001
60-69 -0.2007 0.0002
DENTSTIM
70+ -0.3956 0.0001
60-69 -0.3328 0.0001
Female 0.1720 0.0005
* Multiple linear regression (forward, p-in I0.05), using dummy variables for age
groups, gender, ethnicity, and education level.
ethnicity, and education level on DFS, those in the two younger age groups
PATRESP, and DENTSTIM were per- (approximately one in five respon-
formed (Table 1).Dummy variables dents) than among those in the older
were constructed for each of these groups. However, cancelation or fail-
features and entered stepwise (for- ure to appear was apparently quite
ward, p-in I 0.05). Variables repre- uncommon regardless of age group.
senting the two oldest age groups Significant gender-related differences
(60-69 and 70 & over) were signifi- were not found for either item.
cantly related to lower values for all In order to evaluate age- and gen-
three of the measures (p < 0.001). der-specific physiologic responses to
Female gender was significantly dental fear and anxiety, we examined
related to higher values for DFS and only respondents who reported expe-
DENTSTIM (p < 0.001). The stan- riencing a ”major” response. A
dardized regression coefficients for “major” response is defined here as a
the two age variables were similar report of experiencing the physiolog-
and (when gender was significant) ic response ”often” or “nearly every
approximately twice those for female time”. For each physiologic response,
gender. Ethnicity and education level the two oldest age groups reported a
were not significantly related to the markedly lower frequency of ”major”
fear and anxiety measures, but very responses than the younger groups.
little statistical power was available Among those who reported ”major”
for those tests in this sample. physiologic responses to having den-
Two DFS items relate to behav- tal work done (Table 2), muscle ten-
ioral responses prior to a dental sion was the most common for all
appointment-avoiding making the four age groups, but varied from
appointment, and canceling or failing 32.3% within the age 40-50 group to
to appear-and may be considered 12.2% among those 70 or older.
an indirect indicator of dental anxiety Among those in the two younger age
and fear. Avoidance was significantly groups, 18-20% reported that an
more common (p < 0.001) among increased heart rate was common,
84 SCD Special Care in Dentistry, Vol17 No 3 1997
6.2% for 60-69, and 3.1%for those 70
and older. Increased breathing rate
was also reported more often by
those under 60 (16.2%for ages 20-30
and for ages 40-50) than by those 60-
69 (8.6%) or over 70 (3%). Reporting
of perspiration was far more common
for those under 60 (15-16%)than for
those over 60 (1-3%).None of those
60 or older reported feelings of nau-
sea. All of these responses except
nausea were significantly related (p <
0.05) to age group. Again, categorical
variables were not statistically related
to gender for any of these physiologic
responses.
Age and gender differences were
examined regarding dental stimuli
which subjects reported as producing
“major” degrees of fear and anxiety.
“Major” stimuli are defined as pro-
ducing “a fair amount” of or “a great
deal” of fear and anxiety (Table 3).
Among all age groups, five stimuli
(listed here in order of descending
frequency) stood out as the most
notable (24-32% VS. 4-11% for other
stimuli): hearing the drill, feeling the
needle injected, seeing the needle,
feeling the drill, and seeing the drill.
Each became progressively less
important with increasing age of the
respondents. For every stimulus, the
frequency of reported ”major”
degrees of fear and anxiety was sig-
nificantly lower for those over 60
than for those under 60 (p < 0.05).
Several of the dental stimuli were
related to gender. Females were sig-
nificantly more likely (p < 0.05) than
males to have “major” degrees of fear
and anxiety regarding ”hearing the
drill”, “feeling the needle injected”,
”feeling the drill in mouth, ”having
teeth cleaned”, and “approaching the
dental office” (listed here in decreas-
ing order of frequency).
The final item in the DFS provides
a convenient single-item summary
measure of overall fearfulness. The
behavior of this item serves as a
check and confirmation of the previ-
ously discussed measures. Level of
fear as measured by this single sum-
mary item was sigruficantly related
(p < 0.05) to both age group and gen-
der. Levels of fear were similar for
those 20-30 and 40-50 years old.
Table 2. Percent of dentate respondents reporting “major” fear/anxiety-mediated behavioral or physiologic responses (report of
experiencing “often” or “nearly every tlme”).
Age 20-30 Yrs
Behavioral responses
prior to dental
appointment
Avoid making
appointment* 17.2
Cancel or fail to appear
for appointment 1.0
Physiologic response
when in dental chair
Muscles became tense“ 22.2
Heart beat faster* 18.2
Breathing rate increased* 16.2
Perspired* 15.2
Felt nauseated or sick 5.0
* Sigruficant across four age groups (p c 0.05, Chi-square for ”major” response 0,l).
However, they were approximately
three times more likely to express
“major” levels of overall fearfulness
than those 60-69 and nearly six times
more likely than those 70 and older.
Females were more than twice as
likely as males to express ”major”
levels of overall fearfulness.
Discussion
As noted above, the study partici-
pants were identified through a ran-
domized selection process within age
quotas. Nevertheless, sample charac-
teristics differ from those reported for
the underlying population of metro-
politan Denver at the time of the sur-
vey. For example, employed persons
in metropolitan Denver represented
73% of individuals 15-65years of age,
while in the sample, 65% of those 20-
65 were employed.21The proportion
of the sample having completed high
school (91%)was higher than the 81%
proportion reported for metropolitan
Denver in 1980.22The sample under-
represented Hispanics (3% of respon-
Age 40-50 Yrs Age 60-69 Yrs Age 70+
21.2 6.2 1.5
2.0 1.2 0 1.2
32.3 14.8 12.2
20.2 - 6.2 3.1
16.2 8.6 3.0
16.1 1.2 3.0
5.1 0 0
dents) and Blacks (2% of respon-
dents), who make up 10.5%and 4.8%
of the metropolitan Denver popula-
tion, re~pectively.~~
The oral health status of this sarn-
ple differed from that of the 1985-86
NIDR Survey of Oral Health.24
Totally edentulous individuals were
under-represented in the Denver
sample (25% of those over 60 and
none under 60), when compared with
the NIDR results (41% of those over
65 and 4.2%of those under 65). Self-
reported utilization of dental services
within the past year was higher in the
Denver sample (68%) than in the
NIDR sample (52%,also based on
self-reports).While the stratified
Denver sample is appropriate for
between-group comparisons, it does
not provide the type of representa-
tive population prevalence data
made possible by the methodology
used in the NIDR study.
The data for this study are consis-
tent with other published observa-
tions of dental fear and anxiety. For
example, the mean DFS score of 37.6
SCD Special Care In Dentistry, Vol17 No 3 1997 85
All Ages All Ages, Male All Ages, Female
12.8 8.2 14.9
0 1.7
21.4 17.3 23.4
13.0 11.8 13.7
11.9 11.8 11.9
9.8 10.9 9.4
2.9 0.9 3.8
is similar to means from a number of
other reports, summarized by
Schuurs and H ~ o g s t r a t e nThe
. ~ ~most
commonly reported fear/anxiety-
producing dental stimuli (those relat-
ed to drilling and injections) were
also comparable with stimuli noted
in other ~ t u d i e s . ~ J ~
These data are also consistent with
observations that the frequency of
reporting significant anxiety is age-
related. The greatest reduction in fre-
quency has been reported to occur at
about age 40.3,8The Denver sample’s
results were similar. That is, the dif-
ferences in the Denver sample’s over-
all levels of fear and anxiety were
more noticeable between the
youngest two age groups and the
oldest two age groups, with the
greatest reduction observed some-
time after age 50. Whether due to a
decreased pain response, increased
familiarity with dental stimuli over
time (fewer ”unknowns”), or gradual
accommodation/resignation to expe-
rience (whether pleasant or noxious),
older age (greater than 50) does
appear related to reduced anxiety
about dental treatment. It should also
be stressed, however, that due to sig-
nificant physiological decline and
multiple chronic disease prevalence
in many elderly patients, even mod-
erate levels of anxiety may produce
significant iatrogenic consequences
when patients receive invasive dental
therapies. Low-stress protocols and
careful patient monitoring, therefore,
should be routinely utilized with all
"at r i s k older adults, even when
they self-report low fear and anxiety.
The frequency of dental fear and
anxiety in this sample was also par-
tially gender-related. While there was
no significant relationship of the
Dental Fear Survey (DFS) and the
Patient Response Scale (PATRESP)
with gender, the Dental Stimulus
Response Scale (DENTSTIM)and
overall fearfulness were both signifi-
cantly higher for females. With
regard to specific physiologic
responses, there were no pronounced
gender differences in this sample.
However, for some specific dental
stimuli, females did report being
more fearful than males (especially in
response to "feeling the drilI in the
mouth"). Interestingly, females were
much more likely than males to be
anxious about approaching the den-
tal office and having their teeth
cleaned. These relationships might be
due to actual fear and anxiety differ-
ences, perhaps related to the social-
ization process for men and women.
Alternatively, the tendencies reflect-
ed in these data may simply reveal
gender differences in willingness to
self-report anxiety, with males dis-
playing a disinclination to do so.
Conclusions
,Ingeneral, the results from this sur-
vey of the general population of a US
metropolitan area are comparable
with the findings of most recent
European and Canadian surveys.
These data indicate that fear and anx-
iety may be more prevalent among
relatively younger patients than older
patients. This study tested two sum-
mary dependent variables based on
components of Kleinknecht's Dental
86 SCD Special Care in Dentlstry, Vol17 No B 1997
Fear Survey, the Patient Response
Scale (PATRESP)and Dental
Stimulus Response Scale (DENTSTIM).
These variables appeared to summa-
rize accurately the findings related to
physiologic responses and fear/anxi-
ety-producing dental care stimuli.
Among specific fear /anxiety-pro-
ducing stimuli, the most commonly
noted were those categorized by
Kleinknecht7 as associated with treat-
ment. These were related to injections
and the use of handpieces. Stimuli
categorized as being associated with
early steps in making and keeping a
dental appointment were less com-
monly observed, particularly for
males. These included such items as
approaching the office or seeing the
dentist walk into a room. It would
seem, therefore, that succes5ful clini-
cal tactics for allaying fear and anxi-
ety may be most critical during the
first appointment at which invasive
treatment is rendered. This appears
to be particularly true for younger
age groups, in whom dental fear and
anxiety are most pronounced. The
declining salience of dental fear and
anxiety with aging suggests that, if
properly addressed during the
younger years, fear and anxiety may
rarely become an issue among mem-
bers of future cohorts of elders.
Additional investigations could pro-
duce useful information about a
fear/anxiety-prone subgroup and the
development of age-specific and per-
haps gender-specific mechanisms
and techniques for addressing dental
fear and anxiety.
Dr. Holtzman is on the faculty of the
Department of General and Hospital Dentistry,
UMDNJ New Jersey Dental School, 110 Bergen
Street, Newark, New Jersey 07103-2400, USA.
Drs. Berg and Berkey are on the faculty of the
Department of Applied Dentistry, University
of Colorado School of Dentistry, Denver,
Colorado, USA. Dr. Mann is on the faculty of
the Hebrew University, Hadassah School of
Dental Medicine, Jerusalem, Israel.
Correspondence should be addressed to Dr.
Holtzman.
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