Frequently asked questions

What is dental anxiety?

Dental anxiety is an aversive psychological response to a poorly defined, or not immediately present dental stimulus interpreted as potentially harmful or dangerous, usually within a dental context.

This definition is distinct from dental phobia which is characterised essentially as an individual who avoids dental treatment and can be recognised with the following criteria:

• A marked and persistent fear of the specific object or situation that is excessive or unreasonable
• An immediate anxiety response upon exposure to the feared stimulus, which may take the form of a panic attack
• Recognition that the fear is excessive or unreasonable
• avoidance of the anxiety-producing situation
• interferes with normal functioning or causes marked distress.

Why choose MDAS to assess dental anxiety?

There are twelve reasons for selecting the MDAS to assess dental anxiety, namely:

1. Quick to complete,
2. Widely used in survey, experimental and clinical studies,
3. Reliability found to be favourable in the UK and other national samples,
4. Evidence for validity, such as relates well to other measures of dental anxiety, and related constructs
5. Identical answering scheme for each question making comparisons simple,
6. Functions well as a screening tool,
7. Acceptability in respondents is high and does not raise anxiety in patients prior to their dental appointment (no significant instrumentation effect).
8. Numerous translations in other languages available,
9. Conversion tables with Corah’s Dental Anxiety Scale available (both directions),
10. Cut-off determined for extreme dental anxiety (from clinical evidence and comparison with DSMIV criteria),
11. Ability to compare with numerous other published studies,
12. Norm referenced with UK representative samples.

Do I need permission to use the Modified Dental Anxiety Scale?

No. The MDAS is freely available. Please quote the source of the measure which is:

HUMPHRIS GM, MORRISON T and LINDSAY SJE (1995) ‘The Modified Dental Anxiety Scale: Validation and United Kingdom Norms’ Community Dental Health, 12, 143-150.

I am not sure whether I want to measure dental anxiety with the MDAS. There seems to be a number of measures available?

All researchers have the challenge to select the measure that best reflects their interest and research question.

There are a number of measures available.

Dr Stan Lindsay and I were dissatisfied with the original Corah version of the Dental Anxiety Scale for number of reasons (early 1990’s), including:

• The answering scheme was not standard across the question items
• The categories were not in consistent rank order (i.e. tense and anxious can be reversed according to some respondents) and
• There was no question about local anaesthetic.

The later appeared an omission because a major feature of dental anxiety for many respondents is the ‘needle’.

You should inspect other measures of Dental Anxiety and decide which is correct for your study. The MDAS has advantages as can be seen in the list of 12 reasons to select this measure. No measure is perfect and one issue is that the MDAS is brief.

There are measures that have greater length and go into greater detail than the MDAS. In addition the MDAS is merely a catalogue of respondent’s views to typical situations in the dental environment and does not attempt to reflect a theoretical position.

So make a selection of the measure that best fits your research question. You are advised not to design a new measure unless you are dissatisfied with what is available in the literature. The work involved is considerable.

What is the scoring procedure for the MDAS?

Simply sum the scores of the five items which have been coded from 1 to 5 (not anxious to extremely anxious respectively).

You should get a scale that ranges from a minimum of 5 to a maximum of 25.

Sometimes a respondent will not reply to some of the items. What do you recommend to do with missing data?

You can calculate a mean score based upon the remaining scores as long as no more than one item on the five-item scale is missing.

You may consider that you can cope with 2 items missing but bear in mind that your score then depends on almost a proxy of only just over half of the data being present.

For a single item pro-rating you can use the SPSS command:

• COMPUTE MDAS = Mean.4 (MDAS1, MDAS2, MDAS3, MDAS4, MDAS5)

Other methods can be considered which require specialist advice such as regression, hot deck, or multiple imputations techniques such as MCAR.

What are the norms of the MDAS?

The original paper by Humphris et al (1995) presented some norms for different samples in the UK.

More recently this has been updated for UK and can be accessed free in an Open-Accessed journal (see publication list) or use this link: http://www.biomedcentral.com/1472-6831/9/20.

Is the MDAS one-dimensional?

The MDAS has traditionally been treated as a single measure of dental anxiety, but recent evidence suggests that it may also provide information about two related areas of dental anxiety.

The Modified Dental Anxiety Scale (MDAS) contains five questions, each rated on a five-point response scale. Traditionally, the five responses have been added together to produce a total MDAS score ranging from 5 to 25. This total score remains an important and well-established way of describing a person’s overall level of dental anxiety.

However, closer examination of the content of the five questions suggests that they cover two somewhat different areas.

What are the two areas of dental anxiety?

Items 1 and 2 concern anticipatory dental anxiety.

These questions ask about how a person would feel in anticipation of going to the dentist and waiting for treatment. They therefore concern anxiety that may occur before the dental treatment itself takes place.

Items 3, 4 and 5 concern treatment-related dental anxiety.

These questions ask about increasingly specific dental procedures, including having teeth drilled and receiving a local anaesthetic injection. They therefore concern anxiety associated more directly with dental treatment and procedures.

What does the research tell us?

Until recently, the MDAS was generally regarded as a unidimensional measure: that is, the five questions were assumed to reflect one underlying characteristic called dental anxiety.

A recent study by Humphris and Newton (2025) re-examined this assumption using both a theoretical analysis of dental anxiety and statistical modelling of data from the UK Adult Dental Health Survey. The analysis found evidence supporting a two-construct formulation in which anticipatory and treatment-related dental anxiety could be distinguished.

Importantly, the two aspects were strongly related to one another. This means that they should not be regarded as two completely separate forms of dental anxiety. Rather, they appear to represent two related aspects of the broader experience of dental anxiety.

The study also found some differences in how the two components related to other characteristics. For example, anticipatory dental anxiety showed a stronger relationship with oral-health-related quality of life than treatment-related dental anxiety, as predicted by the theoretical model. The two components also showed different patterns in relation to age and previous experience of dental visits.

Have other investigators found this?

Yes. The evidence for distinguishing anticipatory and treatment-related aspects of dental anxiety is not confined to the recent UK analysis.

Yuan and colleagues (2008), including Satu Lahti and Gerry Humphris, examined the Chinese translation of the MDAS using confirmatory factor analysis and structural equation modelling, with cross-validation in an English comparison sample. They identified two correlated factors: anticipatory dental anxiety and treatment dental anxiety. They concluded that the Chinese MDAS could assess overall dental anxiety while also assessing these two correlated but distinct aspects.

The research group led by Professor Satu Lahti at the University of Turku, Finland, has also examined the two-factor structure. In a large study of expectant mothers and their partners, Lahti and colleagues (2020) specifically tested the factor structure of the MDAS and examined the relationships of the two factors with general anxiety and depression.

Further evidence has subsequently appeared from other countries. For example, a Swedish validation study found support for a two-factor model of the Swedish MDAS, although the two factors shared substantial variance (78%). The authors described the two factors as anticipatory dental anxiety and treatment-related dental anxiety.

The recent Thai-MDAS study provides another contemporary example of cross-cultural validation. The accumulating international evidence therefore suggests that the distinction between anticipatory and treatment-related dental anxiety may be a feature of the MDAS that can be observed across different language and cultural versions, although the strength and precise interpretation of the two factors may vary between populations.

Does this mean that the MDAS should now be regarded as two separate scales?

Not necessarily.

The MDAS remains a brief and well-established five-item measure of overall dental anxiety, and the total score remains useful. The new evidence suggests, however, that the five items may contain additional information that is lost when only the total score is reported.

For research purposes, it may therefore be useful to report:

• the total MDAS score (items 1–5);
• the anticipatory dental anxiety score (items 1–2);
• the treatment-related dental anxiety score (items 3–5).

This approach allows researchers to retain the familiar total MDAS score while also examining whether a person’s anxiety is particularly prominent in anticipation of a dental visit or in relation to dental treatment itself.

Why might this distinction be useful?

The distinction may be clinically and psychologically meaningful.

For example, two people could have similar total MDAS scores but arrive at those scores in rather different ways. One person might be particularly anxious about making or attending a dental appointment, while another might have relatively little anticipatory anxiety but become highly anxious when faced with specific dental procedures.

Recognising this possibility may eventually help researchers and clinicians understand dental anxiety in greater detail and investigate whether different types of anxiety respond differently to particular forms of support or intervention.

At present, however, further research is needed to establish how useful the two components are in routine clinical practice. The evidence for the two-construct interpretation is promising, but it should be regarded as an extension of our understanding of the MDAS, rather than as a replacement for the established total score.

Does this change how I should complete the MDAS?

No.

The MDAS should continue to be completed in its established five-item form. The five questions should not be altered or replaced.

The principal change concerns how the information may be interpreted. In addition to the established total score, researchers may wish to examine the two component scores:

Anticipatory dental anxiety: MDAS items 1 + 2

Treatment-related dental anxiety: MDAS items 3 + 4 + 5

These component scores should currently be regarded as research-informed additional information, rather than as replacements for the established MDAS total score.

References mentioned in this section

Humphris, G. M., & Newton, J. T. (2025). Is the Modified Dental Anxiety Scale (MDAS) a single or two construct measure? A theoretical and pragmatic perspective. Dentistry Journal, 13(2), 68. https://doi.org/10.3390/dj13020068.

Yuan, S., Freeman, R., Lahti, S., Lloyd-Williams, F., & Humphris, G. (2008). Some psychometric properties of the Chinese version of the Modified Dental Anxiety Scale with cross validation. Health and Quality of Life Outcomes, 6, 22. https://doi.org/10.1186/1477-7525-6-22.

Lahti, S., Suominen, A., Freeman, R., et al. (2020). Association of depression and anxiety with different aspects of dental anxiety in pregnant mothers and their partners. Community Dentistry and Oral Epidemiology. https://doi.org/10.1111/cdoe.12511.

Höglund, M., Göranson, E., Wårdh, I., et al. (2024). Cross-cultural adaptation and validation of the Swedish version of the Modified Dental Anxiety Scale. Acta Odontologica Scandinavica, 83, 666–671. https://doi.org/10.2340/aos.v83.42436.

Rattanawonsakul, K., Krongvanitchayakul, R., Osiri, S., et al. (2026). Thai Modified Dental Anxiety Scale (Thai-MDAS): cross-cultural adaptation, psychometric validation, and preliminary diagnostic accuracy. BMC Oral Health, 26(1), 1713. https://doi.org/10.1186/s12903-026-09580-0.

Is there a point along the scale that could be considered as a cut-off?

The current cut-off is 19.

This in some ways is controversial as the construct of dental anxiety is a continuum. Hence trying to fix a point along the scale is far from easy in which a researcher might consider a person to be very dentally anxious.

From a practical point of view however it is sometimes helpful to be alerted that if someone scores at or above a certain level then that person could be considered as satisfying a certain profile or requires some assistance. This is very much a clinical decision and the clinician who wishes to use the MDAS in this way should be aware that the measure is an approximation and not a hard and fast decisional aid.

Therefore those that score at 19 or above this score would be considered as ‘very dentally anxious’.

The likelihood of being dentally phobic is hard to determine as dental phobics would prefer not to complete such a measure and therefore we do not have a good evidence base.

Suffice to say that the MDAS is the only dental anxiety measure to date that has based its cut-off (for very dentally anxious patients requiring extra clinical attention by the dental member of staff) on a clinical sample (Humphris et al 1995) and also with a large community sample (King and Humphris, 2010).

I have collected my data using the Corah version of the Dental Anxiety Scale. Can I compare my scores with MDAS values?

Yes. There are Conversion Tables and SPSS routines available to perform this set of calculations.

You can also do the reverse (i.e. convert MDAS to CDAS scores).

See the reference of Freeman et al (2007) for details.