Kassem 

El Hajj et al. BMC Oral Health (2021) 21:48

https://doi.org/10.1186/s12903-021-01409-2

RESEARCH ARTICLE Open Access

Assessment of dental anxiety and dental

phobia among adults in Lebanon
Hiba Kassem El Hajj, Youssef Fares and Linda Abou‑Abbas* 

Abstract 
Background:  Dental anxiety continues to be a widespread problem affecting adult populations. The primary aim of
our study was to evaluate the psychometric properties of the Lebanese Arabic version of the Modified Dental Anxiety
Scale (MDAS-A) and to identify the optimal cut-off for assessing dental anxiety and dental phobia among adults in
Lebanon. In addition, we sought to assess dental anxiety and phobia as well as their correlates among Lebanese adult
patients.
Methods:  A cross-sectional study was carried out on a sample of 451 dental adult patients aged between 18 and
65 years old. Information about demographic characteristics, previous bad dental experience, trauma’s experience
period, perception of a periodontal problem, sensation of nausea during dental treatment, the MDAS-A scale, and the
Visual Analogue Scale for anxiety (VAS-A) were collected.
Results:  MDAS-A exhibited evidence of adequate psychometric properties. The optimal cut-off was 12 for dental
anxiety and 14 for dental phobia. Out of the total sample, 31.5% suffered from dental anxiety while 22.4% had a
dental phobia. Multivariable analysis showed that the odds of dental anxiety and phobia were higher among females
compared to males. Also, patients suffering from periodontal problem perceptions, bad dental experiences during
childhood and adolescence, and the sensation of nausea during dental treatment were at a higher risk of developing
dental anxiety and phobia compared to their counterparts. However, a higher level of education was found to be a
protective factor against dental phobia among Lebanese adult patients.
Conclusion:  The MDAS-A scale is a suitable tool for the routine assessment of dental anxiety and phobia among
Lebanese adult patients. Identifying patients with dental anxiety at the earliest opportunity is of utmost importance
for delivering successful dental care.
Keywords:  Modified dental anxiety scale, MDAS, Psychometric evaluation, Lebanese, Arabic version

Background oral health. Progressive worsening of the untreated oral

Despite the recent innovation and technological diseases coupled with the feeling of guilt, shame, or infe-
advances in modern dentistry, dental anxiety contin- riority contribute to a further increase in dental anxiety,
ues to be a widespread problem affecting child and and the vicious cycle continues [3]. On the other hand,
adult populations. Several researchers have described a patients with dental anxiety are a considerable source of
“dynamic vicious cycle” relating dental anxiety to bad oral stress that can compromise the dentists’ clinical perfor-
health [1–3]. Patients with dental anxiety tend to delay mance [4]. Thus, there is a need to identify patients with
or avoid dental care which will result in worsening their dental anxiety before treatment initiation. This can help
dental care providers to break the vicious cycle and to
*Correspondence: [email protected] provide effective treatment [5, 6].
Neuroscience Research Center, Faculty of Medical Sciences, Lebanese A clinical diagnostic interview is required to estab-
University, Beirut, Lebanon lish a definite diagnosis of dental anxiety. Furthermore,

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Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 2 of 10

having a valid and reliable instrument is of great impor- Procedure

tance in clinical settings. In response to this need, Information about the demographic characteristics (age,
researchers have developed various specific instru- gender, marital status, education level), previous bad den-
ments to evaluate dental anxiety [7, 8]. One of them is tal experience, trauma’s experience period, perception of
the Modified Dental Anxiety Scale (MDAS) which is periodontal problem, sensation of nausea during den-
used frequently for this purpose [9]. tal treatment, the Arabic version of the Modified Dental
MDAS is an adaptation of the original Corah’s dental Anxiety Scale (MDAS-A), and the Visual Analogue Scale
anxiety scale (CDAS) which is a 4-item tool request- (VAS-A) were collected from the participants. To deter-
ing patients to estimate their anxiety levels in four dif- mine the test–retest reliability of the MDAS-A scale, 30
ferent dental situations [10]. MDAS was proposed by patients were recruited to complete the MDAS-A scale
Humphris et al. to improve the original CDAS by add- twice. The time between the two tests was 2 weeks. The
ing a question about getting local anesthetic injections questionnaires were distributed to 500 patients, 451 were
and requesting the possible replies to each question in completed which corresponded to an overall effective
a Likert scale ranging from “not anxious” to “extremely response rate of 90.2%.
anxious” [9]. MDAS was initially established in the
English language and authors have revealed good psy- Study measurements
chometric properties among adults in several English- Modified Dental Anxiety Scale (MDAS)
speaking countries such as United Kingdom [9, 11, 12], The MDAS consists of 5 questions to measure the degree
Ireland [11], and Wales [13]. of dental anxiety in 5 situations: preparing for a dental
Due to the influence of linguistic and cultural dif- visit, waiting in the dentist’s office for treatment, sitting
ferences, MDAS has been translated and adapted to in the dental chair for drilling, getting ready in the den-
several languages including Chinese [14], Nepali [15], tal chair for scaling, and preparing for local anesthetic
Malay [16], Greek [17], Spanish [18], Tamil [19], Turk- injection. Evaluations range from “non-anxious” [1] to
ish [20], Italian [21] and Arabic [5, 22–24]. In the Arab “extremely anxious” [5]. The total score ranges from 5 to
world, the psychometric properties of the MDAS were 25 while higher scores indicating severe anxiety.
tested in two groups of adult Arabic-speaking individu- Items of the MDAS have been translated and adapted
als in Saudi Arabia only [5, 24]. to the Arabic language in Saudi Arabia [5]. The Arabic
Given that the spoken Arabic dialects differ consider- dialects differ across the Arab countries, so there was a
ably across the Arab cultures and countries, it is recom- need to cross-culturally adapt the Arabic version to the
mended to adapt and validate the translated measuring Lebanese dialect. Thus, a review committee consisting
system in other Arabic countries. Additionally, test- of two dentists and an epidemiologist, who are native
ing another Arabic version can assign more informa- English speakers, revised the Arabic version. They were
tion about its validity and reliability. Thus, the current asked to consider whether the items are a good fit for
study aims to test the psychometric properties of the the Lebanese adult population. Only, the fourth item of
Lebanese Arabic version of the MDAS and to identify the MDAS Arabic version has been an area of discus-
the cut-off to determine anxiety and phobia. Besides, sion between the review committee who agreed that the
we sought to assess dental anxiety and phobia and to Lebanese population could not understand the Arabic
determine their associated factors in a group of Leba- translation of “teeth scaled and polished”. Therefore, this
nese adults. sentence was glossed with an explanation of “cleaning” in
brackets after consensus between committee members.
Finally, a new Arabic version adapted to the Lebanese
Methods culture was produced and referred to as MDAS-A.
Study design and population A pilot study on a group of thirty patients was con-
This was a cross-sectional study conducted from March ducted to check the clarity of the Arabic items. The test
until June 2019. Patients were recruited at 29 private Leb- was completed within 4  min and no difficulties were
anese dental clinics. The inclusion criteria consisted of reported.
being Lebanese, aged between 18 and 65 years, and able
to write and read the Arabic language. Pregnant women
The Visual Analogue Scale for Anxiety (VAS‐A)
as well as patients with malignant diseases and mental
disabilities were excluded from the study. The guideline To study the validity, patients rated their current level of
for Strengthening the Reporting of Observational Studies dental anxiety on a 100  mm scale, where zero indicated
in Epidemiology (STROBE) was followed when reporting “not at all anxious” and 100 indicated “extreme dental
this study [25]. anxiety”. Previous studies have confirmed the validity and
 Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 3 of 10

reliability of VAS-A in assessing dental anxiety [26–28]. characteristic (ROC) curve was applied and the Youden
Thus, researchers can use the VAS-A to assess dental index was calculated. Multivariable logistic regression
anxiety, with the cut-off of ≥ 51 for anxiety and ≥ 70 for analyses were performed to identify associated factors of
phobia [28]. dental anxiety and phobia. Adjusted odds ratio and their
95% confidence intervals were reported. The final logis-
Statistical analysis tic regression model was reached after ensuring the ade-
The statistical software SPSS version 22.0 was used for quacy of our data using the Hosmer and Lemeshow test.
analyses. Means and standard deviations (SD) were used All statistical tests were two-sided, and the significance
to report descriptive statistics for continuous variables level was set at 0.05.
and frequency with percentages for categorical variables.
Cronbach’s alpha was used to assess the internal consist-
ency of the MDAS-A scale. The test–retest reliability was Results
assessed by calculating the intra-class correlation coeffi- Baseline characteristics of the study sample
cient (ICC). ICC values between 0.40 and 0.59 are con- Table 1 displays the demographic characteristics of the
sidered fair, values between 0.60 and 0.74 are good and whole sample and the two split samples. The mean age
between 0.75 and 1.0 are excellent [29]. Sample size guid- was 34.13 (SD = 10.96) ranging from 18 to 65 years. Of
ance indicated that 200–300 participants per scale item the total, 65.5% were females and 60.5% had a univer-
would be adequate for establishing sufficient evidence sity level of education. There were no significant differ-
of scale validity and reliability [30]. Thus, the total group ences in age, gender, and education level between the
was randomly divided into two groups using the ran- two split samples.
domization function on SPSS 22.0. In the first random-
half sub-sample (n = 225), the exploratory factor analysis
(EFA) was performed through the principal components Reliability of the MDAS‑A scale
analysis using Varimax rotation. Confirmatory factor The MDAS-A total mean score was 10.1 with a stand-
analysis (CFA) was performed in the second random-half ard deviation of 4.78. The internal consistency of the
sub-sample (n = 226) using the Amos software version MDAS-A total scale was calculated using Cronbach’s
22.0. The goodness-of-fit of the models were evaluated alpha. For the total sample of 451 participants, the
using Chi-square (χ2) and degrees of freedom (df ), Root MDAS-A demonstrated high internal consistency with
Mean Square Error of Approximation (RMSEA), Good- an alpha coefficient of 0.91. The Corrected–item to
ness of Fit Index (GFI), and Comparative Fit Index (CFI). total correlation coefficients ranged from 0.68 to 0.82
Spearman correlation coefficient was used to assess indicating that each item contributes significantly to
convergent validity by correlating MDAS-A to VAS-A the total MDAS-A scale. Deleting an item from the
scores in the total sample. MDAS-A total scores were construct did not significantly change the alpha level
compared between patients with and without anxiety as (Table  2). The test–retest ICCs were calculated for the
well as phobic and non-phobic participants using inde- five individual items and the total score. The results of
pendent-samples t-test to determine the criterion validity the MDAS-A total score were excellent with an ICC of
of the scale. To find the optimal cut-off value for detect- 0.932 suggesting strong reproducibility (Table 3).
ing dental anxiety and phobia, the receiver-operating

Table 1  Characteristics of the whole study group and the Random Split-Half Samples

All sample (N = 451) Split Sample 1 (n = 225) Split Sample 2 (n = 226) P value

Age mean (SD) 34.1 (11.0) 34.7 (11.5) 33.5(10.3) 0.275

Gender n (%) 0.972
 Male 158 (35.0) 79 (35.1) 79 (35.0)
 Female 293 (65.0) 146 (64.9) 147 (65.0)
Educational level n (%) 0.684
 Primary 27 (6.0) 12 (5.3) 15 (6.6)
 Complementary 76 (16.9) 41 (18.2) 35 (15.5)
 Secondary 75 (16.6) 34 (15.1) 41 (18.1)
 University 273 (60.5) 138 (61.3) 135 (59.7)
N or n Frequency, % percentage, SD Standard deviation, P value < 0.05 is significant
Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 4 of 10

Table 2  Internal consistency of the MDAS-A scale (N = 451)

MDAS-A item Mean (SD) Scale mean if item Scale variance Corrected item-total Cronbach’s alpha Cronbach’s
deleted if item deleted correlation if item deleted alpha

Visit tomorrow 1.8 (1.01) 8.26 15.28 0.82 0.88

Waiting room 1.8 (1.04) 8.28 15.14 0.81 0.88
Use of drill 2.2 (1.17) 7.85 14.17 0.82 0.87
Scale and polish 1.91 (1.11) 8.15 15.62 0.68 0.90
Injection 2.34 (1.23) 7.72 14.50 0.72 0.90
MDAS-A total 10.1 (4.78) 0.91
MDAS-A: Lebanese Arabic version of the Modified Dental Anxiety Scale; SD, Standard deviation

Table 3 Intraclass correlation coefficients for  test–retest Table 5 Summary statistics of  the  whole model fit
reliability of the five items and total score of the MDAS-A for the unidimensional factor of the MDAS-A
(n = 30)
χ2 χ2/df CFI GFI RMSEA
MDAS-A item ICC 95% CI †
Model A 37.97 7.59 0.96 0.931 0.171
Visit tomorrow 0.938 0.870–0.970 Model B* 5.89‡ 1.47 0.998 0.990 0.046
Waiting room 0.929 0.851–0.966 2
χ chi-square, df degree of freedom, RMSEA Root Mean Square Error of
Use of drill 0.780 0.538–0.895 Approximation, GFI Goodness of Fit Index, CFI Comparative Fit Index, * as Model
A with the correlation between the two residual errors for the first two MDAS
Scale and polish 0.638 0.239–0.828
items, †P value ˂0.0001, ‡P value = 0.207
Injection 0.858 0.702–0.933
MDAS-A total 0.932 0.857–0.968
all items loading onto a single latent variable as suggested
MDAS-A: Lebanese Arabic version of the Modified Dental Anxiety Scale, ICC
Intraclass correlation coefficient, n frequency by the EFA (Model A). The one-factor model displayed
an unsatisfactory fit which was significant. Inspection of
the modification indices suggested adding error covari-
Table 4 Exploratory factor analysis of  the  MDAS Scale ance between items 1 and 2 of the MDAS-A (Model B).
(n = 225) This modification resulted in a significant improvement
of the fit indices (Table 5). All standardized factor load-
MDAS-A item Communality
ings for the one-factor model were significant at P < 0.01
Visit tomorrow 0.800 suggesting a satisfactory factor loading (Fig. 1).
Waiting room 0.765
Use of drill 0.777 Convergent validity of the MDAS‑A
Scale and polish 0.574 Convergent validity of the scale was assessed using Spear-
Injection 0.611 man’s correlation coefficient relating the total MDAS-A
Eigenvalue 3.53 score and VAS-A score. A statistically significant corre-
Percentage of explained variance 70.55 lation was found (r = 0.72 with a P value < 0.0001) indi-
n frequency, Extraction method: principal component analysis; Rotation cating a strong positive correlation and thus, a good
method: Varimax with Kaiser normalization convergent validity. Spearman correlations between
VAS-A and individual items of the MDAS-A were also
significant (P value < 0.0001).
Factor structure of the MDAS‑A
The first split sample underwent the exploratory factor
analysis of the MDAS-A. The value of the KMO measure Criterion validity of the MDAS‑A
was 0.859 which indicated suitable sampling adequacy, Mean scores on the MDAS-A scale were compared
and Bartlett’s Test of sphericity was statistically signifi- between those diagnosed with and without anxiety (made
cant. Hence, the data was deemed suitable for factor anal- through the VAS-A ≥ 51) using the independent t-test.
ysis. A one-factor structure was derived which included A statistically significant mean difference was found
all the items of the scale and accounted for 70.55% of between the two groups with higher scores for patients
total variance with an eigenvalue of 3.53 (Table 4). with dental anxiety compared to patients without den-
Confirmatory factor analysis was performed to deter- tal anxiety (16.6 vs 8.8, P value ˂0.0001). Mean scores on
mine the unidimensional model of the MDAS-A, that is, the MDAS-A scale were also compared between those
diagnosed with and without phobia (made through the
 Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 5 of 10

Fig. 1  One-factor model of the Arabic version of the Modified Dental Anxiety Scale (MDAS-A)

VAS-A ≥ 70) using the independent T-test. A statisti-

cally significant mean difference was found between
patients with and without anxiety with higher scores for
patients with anxiety (16.6 vs 8.8, P value ˂0.0001). The
same was revealed between patients with and without
phobia with higher scores for phobic patients (17.7 vs
9.0, P value ˂0.0001). These results indicate that MDAS-A
has good discriminant validity. The ROC curve showed a
significant area under the curve (AUC) for dental anxi-
ety (AUC = 0.89, 95% CI (confidence interval): 0.84–0.93)
(Fig.  2) and dental phobia (AUC = 0.91, 95% CI 0.86–
0.95) (Fig. 3). The optimal cut-off score to determine the
dental anxiety on the MDAS-A scale as shown by the
ROC curve was 12, with a sensitivity of 86% and a speci-
ficity of 79%. While for dental phobia, it was 14 with a
sensitivity of 79% and a specificity of 85%.

Assessment of dental anxiety and phobia and their Fig. 2  Receiver Operating Characteristic (ROC) Curve revealing
associated factors in the total sample of Lebanese adults Sensitivity as a Function of 1-Specificity of the Modified dental
Of the total sample, 31.5% suffered from dental anxiety anxiety scale (MDAS) against the visual analogue scale (VAS). The VAS
while 22.4% had a dental phobia. Multivariable analy- threshold of dental anxiety is 51 [28]
sis showed that the odds of dental anxiety was 2 times
higher among females compared to male (adjusted OR
2.05 with 95% CI of 1.23 to 3.40). Patients with a previ- anxiety compared to their counterparts with no previ-
ous bad experience during childhood and adolescence ous bad experience (adjusted OR 3.45 with 95% CI of
were 3.45 and 2.18 times more likely to suffer from 1.63–7.30 and adjusted OR 2.18 with 95% CI of 1.20–3.94
Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 6 of 10

of nausea during dental treatment was found to be a risk

factor for dental anxiety (adjusted OR 3.85 with 95% CI
of 2.31 to 6.40) (Table 6).
Concerning dental phobia, females were at higher risk
compared to males (adjusted OR 2.55 with 95% CI of
1.41–4.61). Patients with a previous bad experience dur-
ing childhood and adolescence were more likely to suf-
fer from dental anxiety compared to their counterparts
with no previous bad experience (adjusted OR 3.74 with
95% CI of 1.72–8.11 and adjusted OR 1.94 with 95% CI
of 1.01–3.73 for childhood and adolescence respectively).
Patients with a perceived periodontal problem were more
likely to suffer from dental phobia (adjusted OR 1.38 with
95% CI of 1.01 to 1.88). The sensation of nausea during
dental treatment was found to be a risk factor for dental
phobia (adjusted OR 3.00 with 95% CI of 1.76 to 5.11).
Finally, a higher educational level was found to be a pro-
tective factor against dental phobia (adjusted OR 0.76
Fig. 3  Receiver Operating Characteristic (ROC) Curve revealing
with 95% CI of 0.58 to 0.98) (Table 7).
Sensitivity as a Function of 1-Specificity of the Modified dental
anxiety scale (MDAS) against the visual analogue scale (VAS). The VAS Discussion
threshold of dental phobia is 70 [28] “Dental anxiety” and “dental phobia” represent a signifi-
cant challenge for both patients and dentists. These two
terms are often used interchangeably; however, they do
for childhood and adolescence respectively). Patients
with a perceived periodontal problem were 1.57 times
more likely to suffer from dental anxiety (adjusted OR Table 
7 Factors associated with  dental phobia
1.57 with 95% CI of 1.18 to 2.10). Finally, the sensation among Lebanese patients
All (N = 451)

Table 
6 Factors associated with  dental anxiety OR adj 95% CI P value
among Lebanese patients Gender 0.002*
All (N = 451)  Male† 1
OR adj 95% CI P value  Female 2.55 1.41–4.61
Trauma’s experience period 0.006*
Gender  No previous ­experience† 1
 Male† 1 0.006*  During childhood 3.74 1.72–8.11
 Female 2.05 1.23–3.40  During adolescence 1.94 1.01–3.73
Trauma’s experience period  During adulthood 1.45 0.70–2.98
 No previous ­experience† 1 0.02* Perception of a periodontal problem 0.046*
 During childhood 3.45 1.63–7.30  No† 1
 During adolescence 2.18 1.20–3.94  Yes 1.38 1.01–1.88
 During adulthood 1.18 0.61–2.30 Sensation of nausea during dental < 0.0001*
Periodontal problem treatment
 No† 1 0.002*  No† 1
 Yes 1.57 1.18–2.10  Yes 3.00 1.76–5.11
Sensation of nausea during dental treatment Education level 0.032
†  ≤ 12 years 1.00
 No 1 < 0.0001*
 Yes 3.85 2.31–6.40  ˃ 12 years 0.76 0.58–0.98
OR adj, adjusted odds ratio; CI, confidence interval OR adj, adjusted odds ratio; CI, confidence interval
† †
  Reference group, factors entered into the model: age, gender, marital   Reference group, factors entered into the model: age, gender, marital status,
status, educational level, the trauma’s experience period, the perception of a educational level, Trauma’s experience period, perception of a periodontal
periodontal problem and the sensation of nausea, *P value < 0.05 is considered problem, and the sensation of nausea during dental treatment, *P value < 0.05 is
statistically significant considered statistically significant
 Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 7 of 10

have distinct differences. Dental anxiety is defined as a fit norm. Thus, it was inspected by ways of the modifi-
patient’s specific reaction toward stress associated with cation indices which revealed proof of a significant cor-
dental treatment in which the stimulus is unknown, relation among the two residual errors of the first two
vague, or not present at the moment [12]. On the other questions of the MDAS-A. An inspection of the first 2
hand, dental phobia is characterized by an extreme and items proposes that they have some overlap as they both
persistent fear of clearly discernible, circumscribed pay particular attention to the expectation of anxiety
objects or situations in dental setting which results in the before dental treatment. So, computing error covariance
individual’s avoidance of attending a dentist at all costs, between the first two items improved considerably the fit
unless possibly when a physical problem becomes over- indices. The consistency of our findings with those pre-
whelming [31]. Dental practitioners are recommended viously reported suggests that the MDAS had good con-
to assess dental anxiety and dental phobia during clinical struct validity.
assessment using a well structured and psychometrically A strong positive correlation linking MDAS-A and
valid scale that could measure the subjective experience VAS-A was revealed suggesting a good level of conver-
of dental anxiety and phobia in an objective way [31]. In gent validity. Such results were also reported by Appu-
response to this need, the purpose of the present study kuttan et  al. [19]. Results of different studies revealed
was to evaluate the psychometric properties of a Leba- moderate correlations between the MDAS and dentists’
nese Arabic version of the MDAS and to assess dental observations (0.4 to 0.66) [9, 34, 37]. In our study, the
anxiety and dental phobia as well as their correlates in a strength of the correlation between the dentist’s observa-
group of Lebanese adults patients. The Lebanese Arabic tions and MDAS scoring was also moderate (results not
version of the MDAS exhibited good validity and reli- shown). This is justified by the reality that some patients
ability evidence. Our results also revealed that female try to hide their dental anxiety in order not to interrupt
patients were at higher risk of developing dental anxiety the treatment process or feel ashamed to share their anx-
and dental phobia compared to males. Besides, previous ieties with their dentists.
bad experiences during childhood and adolescence, peri- Since no Lebanese clinics are specialized in diagnosing
odontal problem perception, and suffering from a sensa- patients with dental anxiety or phobia, the VAS-A was
tion of nausea during dental treatment were risk factors used in the assessment of dental patients as suggested by
for dental anxiety and dental phobia. However, patients Facco et al. [28]. Hence, ROC curve analysis was allowed
with a higher educational level were found to be at lower to estimate the cut-off values for anxiety and phobia in
risk of developing dental phobia. MDAS‐A that best fitted VAS-A data whereby anxiety
Results of our study revealed a good level of inter- and phobia were defined by a score ≥ 51 and a score ≥ 70
nal consistency (Cronbach’s alpha: 0.91) for MDAS-A. on the VAS-A respectively. The ROC curve revealed the
This comes in consistency with the study of Humphris discriminant validity of the MDAS-A scale. The AUC
in 1995 (Cronbach’s alpha: 0.84 to 0.90) [9]. Moreover, value was 0.89 for dental anxiety (95% CI 0.84–0.93) and
the cross-culturally adapted studies of the MDAS such 0.91 for dental phobia (95% CI 0.86–0.95) indicating that
as the Romanian (0.90) [32], Turkish (0.91) [33], Greek the MDAS-A distinguishes between patients with and
(0.90) [34], United Kingdom (0.917) [13], Italian (0.92) without dental anxiety or phobia. The optimal cut-off
[21], and Japanese versions (0.88) [35] reported similar point to distinguish between patients with and without
results. The MDAS-A revealed strong reproducibility dental anxiety is 12 with a sensitivity of 86% and a speci-
over time with an ICC of 0.93. This is consistent with a ficity of 79%. While for dental phobia, it was 14 with a
study that showed a high degree of accordance between sensitivity of 79% and a specificity of 85%. Previous stud-
test and retest reproducibility (0.81 to 0.82) [9], as well ies have reported various cut off for patients with dental
as the study conducted in Japan that reported an ICC of anxiety or phobia with different levels of specificity and
0.91 [36]. sensitivity, maybe due to the use of different diagnostic
The exploratory factor analysis revealed one factor that criteria for the dental anxiety or the populations’ differ-
accounts for 70.55% of the variance. Most studies that ences in their expressing of dental anxiety. The cut-off
inspected the structural validity of the MDAS through point of 19, which has been widely used to spot phobic
EFA revealed strong evidence for a one-factor structure dental patients [9, 33, 38], has a high specificity (99.5%)
[5, 16]. The present study adds to the multiple publica- but beneath sensitivity (0.43). Besides, the cut-off of
tions on the psychometric properties of the Arabic ver- 15 which has been recommended in two studies con-
sion of the MDAS by investigating its factorial validity ducted in Saudi Arabia [24] and Turkey [33] produced a
through Structural Equation Modeling (SEM) proce- high specificity (94%) but lower sensitivity (0.68). Thus,
dures, suggesting that all items support a one-factor we recommend a cut-off point of 14 to screen for den-
structure. The one-factor structure did not have a good tal phobia in a Lebanese population as it had the finest
Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 8 of 10

union of sensitivity and specificity. The MDAS-A should in detecting patients with dental anxiety or phobia and to
be validated against a gold standard such as the Struc- initiate effective strategies to combat anxiety and phobia
tured Clinical Interview for DSM-V to draw definitive among adult patients seeking dental care.
conclusions. The results of the present study need to be considered
Our results revealed that 31.5% suffered from dental in light of several methodological limitations. The possi-
anxiety while 22.4% had a dental phobia. Studies have bility of selection bias due to the convenience sampling
reported a wide range of dental anxiety and dental pho- procedure used to select patients and the absence of ran-
bia prevalence estimates in adult populations. This might domization. We should emphasize that this translated
be related to the fact that the prevalence estimates would Arabic-language form cannot be appropriate to different
differ considerably depending upon the cut-off points Arabic-speaking societies. Other attempts should be con-
used to define a case of dental anxiety or dental phobia. It sidered to adjust the scale to the linguistic characteristics
might also be related to the differences in the scales used of other Arabic-speaking communities.
to assess dental anxiety or dental phobia. Another pos-
sible may be related to culture or to the methodological
variations in terms of study design or sampling methods Conclusion
across studies [31]. Therefore, our results cannot be com- This study was the first to explore the psychometric prop-
pared with others. erties of the Arabic version of the MDAS in Lebanon.
The levels of dental anxiety and phobia were higher Results revealed that the Arabic version of the MDAS has
among females compared to males. This corroborates good validity and reliability. Being female, having previ-
with the results of previous studies [4, 5, 16, 21, 35, 39, ous bad dental experiences during childhood and ado-
40]. The perceived gender difference in anxiety and pho- lescence; reporting having dental fear and a sensation of
bia could be attributed to a combination of emotional and nausea during dental treatment are risk factors for devel-
social factors. Women are more able to express their feel- oping dental anxiety and phobia. Targeting these factors
ings of panic, fear of pain, stress, and depression toward may improve the effectiveness of strategies to decrease
dental procedures while men felt embarrassed and tend anxiety and phobia among adult patients seeking dental
to hide their anxiety and phobia toward dentistry [41]. care.
Furthermore, past traumatic dental experiences during
childhood and adolescence seem to play an important
Abbreviations
factor in increasing dental anxiety and phobia. This result MDAS-A: Lebanese Arabic version of the Modified Dental Anxiety Scale; VAS:
is consistent with previous studies [4, 16, 21, 35]. In fact, Visual analogue scale; SPSS: Statistical Package for Social Sciences; SD: Stand‑
since dental memory is extremely powerful, the upcom- ard deviations; EFA: The exploratory factor analysis; CFA: Confirmatory factor
analysis; χ2: Chi-square; df: Degrees of freedom; RMSEA: Root Mean Square
ing painless dental experience cannot overcome previous Error of Approximation; GFI: Goodness of Fit Index; CFI: Comparative Fit Index;
bad dental experiences [5]. Thus, the previous unpleas- ROC: The receiver-operating curve; ICC: Intra-class correlation coefficient; KMO:
ant dental experience can influence the behavioral inten- Kaiser–Meyer–Olkin Test; EFA: Exploratory factor analysis; AUC​: Area under the
curve; OR: Odds ratio; CI: Confidence interval.
tion to visit a dentist [42], thereby increasing the patient’s
dental anxiety. Acknowledgements
We also found that patients with self-perception of per- The authors would like to thank all the dentists for their help during the data
collection. The authors are also grateful to all patients who accepted to be
iodontal problems were more anxious which was consist- part of this study.
ent with a study conducted in Germany [40]. However,
patients with a higher educational level suffered less from Authors’ contributions
LAA and HKH developed the project idea, performed the literature review,
dental phobia when compared to their less-educated formulated the questionnaire, organized and analyzed the survey, drafted and
counterparts. This is consistent with the studies con- critically reviewed the paper. YF reviewed the manuscript for important intel‑
ducted by Erten et al. [43] and Do Nascimento et al. [44] lectual content. All authors read and approved the final manuscript.
and could be attributed to greater awareness and better Funding
oral health of the patients with a high level of education No funding was received.
as well as their regular visit to dental clinics.
Availability of data and materials
Data are available from the corresponding authors upon reasonable request.
Recommendations for dental routine practice
Ethics approval and consent to participate
Since dental anxiety is a real worldwide problem that Ethical approval was obtained by the scientific research committee of the
results in avoidance of dental care and treatment, it is of Neuroscience Research Center, Faculty of Medical Sciences at the Lebanese
University (Reference number 12/2/2019), Written informed consent approved
great importance to use a valid and reliable instrument by the ethics committee was obtained from all the participants. All the neces‑
that could help in identifying dental anxiety and phobia. sary measures to safeguard participants’ anonymity and confidentiality of
The use of the MDAS-A could help health care providers information were respected.
 Kassem El Hajj et al. BMC Oral Health (2021) 21:48 Page 9 of 10

Consent for publication 21. Facco E, Gumirato E, Humphris G, Stellini E, Bacci C, Sivolella S, et al.
Not applicable. Modified Dental Anxiety Scale: validation of the Italian version. Minerva
Stomatol. 2015;64(6):295–307.
Competing interests 22. Abu-Ghazaleh SB, Rajab LD, Sonbol HN, Aljafari AK, Elkarmi RF,
The author(s) declare that they have no competing interests. Humphris G. The Arabic version of the modified dental anxiety scale.
Psychometrics and normative data for 15–16 year olds. Saudi Med J.
Received: 22 October 2020 Accepted: 19 January 2021 2011;32(7):725–9.
23. Alamri SA, Alshammari S, Baseer M, Assery M, Ingle N. Validation of
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