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15 October 2025

Assessment of Dental Fear and Anxiety Tools for Children: A Review

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1
Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah 21589, Saudi Arabia
2
Ministry of Health, Specialized Dental Center, Madinah 42315, Saudi Arabia
3
Ministry of Health, Specialized Dental Center, Abha 62562, Saudi Arabia
4
Ministry of Health, Specialized Dental Center, Riyadh 11176, Saudi Arabia
Healthcare2025, 13(20), 2597;https://doi.org/10.3390/healthcare13202597
This article belongs to the Special Issue Oral Medicine in Focus: Improving Diagnosis and Treatment Through Continued Education
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Abstract

Background and Objectives: Accurate assessment of Dental fear and anxiety (DFA) is crucial for effective management, yet the vast array of measurement tools presents a dilemma for clinicians and researchers in selecting appropriate methods. This literature review aims to provide a comprehensive review and comparison of the commonly used DFA measurement tools in the pediatric dentistry literature. Methods: A Comprehensive literature search was conducted in December 2024 using the electronic databases PubMed, MEDLINE, ScienceDirect, and Google Scholar. The search was limited to studies focused on identifying research relevant to DFA in children. For each DFA tool, information on its structure, validity, reliability, strengths, limitations, and target population was recruited and tabulated. A comparison between the DFA tools was then conducted. Quality assessment was performed using Patient-Reported Outcome Measures (PRO). Results: The search identified 15 subjective and 5 objective tools. Subjective tools included self-reported scales and pictorial analogs, while objective measures involved physiological monitoring and behavioral observation. While subjective tools offer valuable insights into a child’s self-perceived anxiety, their applicability is influenced by age and cognitive development. Objective measures provide quantifiable data, but require specialized equipment and trained observers. Tools combining simplicity, visual aids, and robust validation were found to be most practical for clinical use. Conclusions: A wide range of valid and reliable tools are available to assess DFA in children. Selection should be tailored to the child’s age, cognitive abilities, clinical setting, and clinician training. Combining subjective and objective assessments may enhance diagnostic accuracy.

1. Introduction

Dental fear and anxiety (DFA) is a typical emotional response in dental settings, affecting individuals across all age groups. In many cases, anxiety experienced during adolescence or adulthood originates from childhood experiences [1]. Therefore, early diagnosis, prevention, and treatment of DFA in children may contribute to better long-term mental health outcomes.
Globally, the prevalence of DFA in children is estimated to range between 20% and 30% [2], and is influenced by factors such as age, cultural background, socioeconomic status, and environmental exposures [3]. Several risk factors have been identified in the etiology of DFA in children, and these are often shaped by dynamic variables such as age, culture, environmental exposures, and generational shifts [4,5,6,7]. These variations highlight the importance of continuous assessment and a thorough understanding of DFA measurement tools [8].
DFA poses significant challenges to the effective delivery of dental care [9]. It often leads to avoidance behaviors, resulting in poor oral health, increased dental neglect, and a higher likelihood of emergency dental treatments [10,11]. Additionally, DFA can have a negative impact on a child’s self-esteem and overall quality of life [12]. Accurate assessment of DFA is, therefore, critical; early identification allows for timely intervention and the prevention of long-term psychological and physical consequences [13]. Nevertheless, pediatric dentists and caregivers must comprehend the factors that lead to subjective dental fear in children, the consequences of untreated anxiety, and the available techniques for assessing and dealing with it [4,5,7,14].
Assessment tools for DFA vary widely. Some of them are subjective tools, determined by the respondent’s viewpoint, while objective tools depend on observed behaviors and the examiner’s interpretation. Subjective dental fear, unlike objective measurement, relies on the child’s perspective and emotional reaction, rather than directly observable or measurable factors, such as physiological responses [15]. Additionally, whosoever responds to the assessment, whether the child, parent, dentist, or another observer, can significantly impact the results [16,17,18,19].
Pediatric dentists must assess a child’s mental health status and level of DFA before initiating treatment. This includes being familiar with the DFA measurement tools. Although there is a systematic review that compares the outcomes of different DFA tools [20] and a review that assesses studies using these tools [21], there is a shortage of reviews that specifically describe the DFA tools used to evaluate pediatric patient fear and anxiety in the dental clinics in a comprehensive and organized manner.
Therefore, this study aimed to provide a review, evaluation, and comparison of the commonly used DFA measurement scales and tools in the literature of pediatric dentistry, in order to guide clinicians and researchers in selecting appropriate tools for assessing and managing DFA effectively.

2. Materials and Methods

A comprehensive literature search was conducted to identify all tools used to assess dental fear and anxiety (DFA) in children, including both subjective and objective measures. In addition, studies evaluating the validity and reliability of DFA tools were included. The search was performed in December 2024 using the electronic databases PubMed, MEDLINE, ScienceDirect, and Google Scholar. The following keywords and Boolean operators were used to retrieve relevant articles: (“dental fear” OR “dental anxiety”) AND (“children” OR “child”) AND (“anxiety scale” OR “anxiety tools”).
The search inclusion criteria included the following: 1—The recruited instrument should be designed specifically for children or have been validated for use in children. 2—The study exclusively assesses dental fear and anxiety. The exclusion criteria were 1—adapted from different tools, 2—tools designed for adults and not used for children, and 3—tools that originally assessed other than DFA, such as pain, and were used in a study to assess DFA.
Search results were screened stepwise: titles, abstracts, and finally, full manuscripts, based on the study aims and eligibility criteria. Eligible studies were reviewed, and data regarding each DFA tool was extracted. Each DFA tool was summarized and tabulated in terms of its definition, validity, reliability, target population, and scoring methods.
A comparative evaluation of DFA tools was conducted, and the strengths and limitations of the subjective tools and DFA scoring items were assessed using the Francis DO et al. It included a Patient Reported Outcome Measures (PRO) checklist, where we used conceptual model (three-items), Content Validity (three-items), Reliability (three-items), Construct Validity (three-items), Scoring & Interpretation (three-items), and Respondent Burden & Presentation (three-items), Ref. [22]; therefore, the scoring will be out of eighteen.
The strengths and limitations of objective physiological measurement tools were evaluated based on Lu JK. et al. 2024 [23] four criteria where adopted from the original paper: continuous monitoring capability (where it will be ideal if the monitoring was constant), device availability and suitability (it will be suitable if it was non-invasive), feasibility of use (it will be ideal if we can use it in research), and cost evaluation (it will be suitable if it come in a low cost).
The search and data extraction was conducted independently by three evaluators (MB, YS, MA). Any disagreements were resolved through discussion with experts (HS and OF).

3. Results

Initially, 40 DFA assessment tools were identified from the search results. Eighteen instruments were selected for comprehensive assessment and inclusion in the study, following a screening for relevance and alignment with the aims of this review. Two scales were excluded because they aimed to measure pain in children, eighteen because it assessed DFA in adults, and two because they evaluated negative beliefs towards dentists. The tools are first classified into subjective and objective measurements, and then into their essential characteristics, validity, reliability, and applicability in pediatric dental settings.

3.1. Subjective Measurements of DFA

Subjective dental fear pertains to the internal feeling of worry or anxiety that a child has before or during a dental appointment. Subjective dental fear, unlike objective measurements, relies on the child’s perspective and emotional reaction, rather than directly observable or measurable factors, such as physiological responses. Pediatric dentists and caregivers must understand the factors that lead to subjective dental fear in children, the consequences of untreated anxiety, and the techniques that are available for assessing and dealing with it.

3.1.1. Corah Dental Anxiety Scale (C-DAS)

Definition: The C-DAS is a self-report scale designed to measure a patient’s level of anxiety about visiting and being at the dentist’s office [24].
Developed by Corah in 1969 [25].
Validity and reliability: C-DAS demonstrated a stability score of 0.77 when tested twice within one week. It also showed significant correlations with other anxiety measures, including the Dental Anxiety Question (DAQ) (r = 0.77, indicating a strong positive relationship), and the State Trait Anxiety Inventory for Children (STAIC) (r = 0.40–0.58, indicating weak to moderate positive relationships (p < 0.01), showing statistical significance [26].
Target population: While C-DAS is primarily designed for adults, some studies have used it for children aged 8 years and above [26,27,28].
Scoring: It consists of four questions with five answers (a 5-point scale from 1 to 5) for each question [29]. The overall dental anxiety score is derived by totaling the scores of the four questions (ranging from 4 to 20); the higher the score, the higher the level of dental anxiety (Table 1).
Table 1. Corah Dental Anxiety Scale (C-DAS).

3.1.2. Modified Dental Anxiety Scale (MDAS)

Tool Definition: The MDAS was introduced as a modified version of the C-DAS. It is a commonly used and validated instrument with which to evaluate dental anxiety in patients.
Developed by Humphris et al. in 1995 [30].
Tool validation and reliability:
The MDAS has demonstrated internal consistency in children, ranging from α = 0.799 to 0.875 across samples [31,32,33]. Criterion validity was supported by correlations with the Children’s Fear Survey Schedule Dental Subscale (CFSS-DS) and a single fear question (r = 0.44–0.58). Construct validity was supported, as children reported lower anxiety during orthodontic treatment compared to higher anxiety when treatment involved local anesthesia [33]. It has also been validated in Arabic, Spanish, Greek, Chinese, Turkish, Romanian, and Tamil [34,35,36,37,38,39,40,41].
Target population: While MDAS is primarily designed for adults, some studies have included children aged 8 years and above [18,42].
Scoring: The MDAS differs from the original DAS by adding an extra question that enquires about the patient’s anxiety just before receiving a local anesthetic injection and secondly, by standardizing the response options across all questions, using a consistent 5-point Likert scale to measure the level of anxiety: not anxious (1), slightly anxious (2), fairly anxious (3), very anxious (4), and extremely anxious (5). Similar to the DAS, the total score is calculated by totaling the scores, resulting in a range from 5 to 25, with higher scores indicating greater anxiety [30] (Table 2).
Table 2. Modified Dental Anxiety Scale (MDAS).

3.1.3. Modified Child Dental Anxiety Scale (MCDAS)

Tool Definition: MCDAS is a modified scale of C-DAS, designed to offer an improved degree of sensitivity and precision in assessing dental anxiety among children [18].
Developed by Wong et al. in 1998 [43].
Tool validation and reliability: The MCDAS demonstrated internal consistency, with item-total correlations ranging from r = 0.60 to 0.74, and Cronbach’s alpha values comparable to those of the Corah Dental Anxiety Scale (C-DAS) and the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). Test–retest reliability demonstrated high stability over one week. Validity was supported by strong correlations with the C-DAS and Dental Fear Schedule Subscale-Short Form (DFSS-SF) (r > 0.70), while construct validity was indicated by higher scores in girls (mean = 20.8) compared to boys (mean = 15.6) and by greater anxiety in older children compared to younger ones. The MCDAS was validated for children aged 8 to 15 years [43]. It has also been validated in Italian and Nepali [44,45].
Target population: The MCDAS is a reliable and valid self-reported scale for assessing dental anxiety in children aged 8 to 15 years [42,43].
Scoring: The scale comprises eight questions designed to assess dental anxiety related to specific dental procedures. Each question is to be answered with a five-point Likert scale, which includes scores ranging from relaxed/not worried (1), slightly worried (2), fairly worried (3), more worried (4), and very worried (5). The total score ranges from 8 to 40, with Higher scores indicating greater dental anxiety (Table 3).
Table 3. Modified Child Dental Anxiety Scale (MCDAS).

3.1.4. The Faces Version of the Modified Child Dental Anxiety Scale (MCDASf)

Tool Definition: It is developed as a modification to the MCDAS by adding a faces analog scale anchored above the original numeric form.
Developed by Howard et al. in 2007 [18].
Tool validation and reliability: The MCDASf in children aged 5 to 12 years demonstrated internal consistency (Cronbach’s α = 0.82), test–retest reliability (intraclass correlation coefficient = 0.80), and criterion validity through correlation with the Children’s Fear Survey Schedule-Dental Subscale (r = 0.80). Construct validity was supported as children evaluated for dental anxiety, with caries, or requiring dental general anesthesia scored higher than those without these conditions. The MCDASf also showed 51% sensitivity and 79% specificity [18]. It has also been validated in Arabic, Turkish, Croatian, Iranian, Malay, and Chinese [46,47,48,49,50,51].
Target population: The MCDASf is a simple, valid, and reliable tool for assessing dental anxiety in young and anxious older children. While Howard et al. validated the MCDASf for children aged 8 to 12 years, they also noted that the scale is suitable for younger children, including those as young as 5 years [18].
Scoring: The questions and scoring are similar to MCDAS (Table 4).
Table 4. The Faces version of the Modified Child Dental Anxiety Scale (MCDASf).

3.1.5. Venham Picture Scale (VPS)

Tool Definition: It is a projective, non-verbal tool designed to assess anxiety levels in children, particularly in dental settings [52].
Developed by Venham and Gaulin-Kremer in 1979 [52].
Tool validation and reliability: The VPS in children aged 3 to 8 years demonstrated internal consistency (Kuder–Richardson 20 = 0.838), test–retest reliability over one week (r = 0.70), and construct validity through an inverse correlation with age (r = −0.47) [19]. According to Buchanan and Niven (2002) [53], the Venham Picture Scale (VPS) in children aged 3–18 years showed low mean scores (1.4). It demonstrated concurrent validity through correlation with the Facial Image Scale (r = 0.70, p < 0.001) [53].
Target population: The VPS is beneficial for children between the ages of 3 and 7, who may have difficulty expressing their anxiety verbally [52]. According to Buchanan and Niven (2002) [53], the tool was effective across a wide age range, from 3 to 18 years. It was quick to administer, making it practical for clinical use with very young children [53].
Scoring: The scale consists of eight pairs of images, each showing a child in both an anxious and a calm state. Children are asked to select one image from each pair that best represents how they feel. Each anxious image chosen is scored as 1, while calm selections are scored as 0. The total anxiety score is calculated by totaling the individual scores, with higher totals indicating greater anxiety. The VPS is quick and easy to administer, and it can be used before, during, or after treatment so as to assess a child’s anxiety level [52] (Figure 1).
Figure 1. Venham Picture Scale (VPS).

3.1.6. Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS)

Tool Definition: It is a widely used tool designed to assess dental fear and anxiety in children [54]. This subscale is part of the larger Children’s Fear Survey Schedule, which evaluates various fears in children.
Developed by Cuthbert and Melamed in 1982 [54].
Tool validation and reliability: The CFSS-DS showed high test–retest reliability (r = 0.97), criterion validity with the Kisling and Krebs behavior rating scale (r = −0.62), and construct validity with higher scores in fearful children (mean 37.8–38.1) compared to non-fearful children (mean 20.9–25.0) [54,55]. It is also validated in Arabic, Chinese, Dutch, Finnish, Japanese, Greek, Hindi, Bosnian, Italian, and Swedish [45,55,56,57,58,59,60,61,62,63].
Target population: The CFSS-DS is commonly applied to children between the ages of 4 and 14 years, as shown in large population-based studies reviewed by Klingberg and Broberg (2007) [64].
Scoring: The scale consists of 15 items describing different dental-related situations or stimuli. Children are asked to rate their fear of each item using a 5-point Likert scale, where 1 represents “not afraid” and 5 represents “very afraid.” The items include: dentists, doctors, injections, having somebody examine your mouth, having to open your mouth, having a stranger touch you, having somebody look at you, the dentist drilling, the sight and noise of the dentist drilling, instruments in the mouth, choking, having to go to the hospital, people in white uniforms, and having the dentist clean your teeth. The total score is calculated by totaling the responses for all 15 items, which range from 15 to 75. Scores from 15 to 31 indicate low dental anxiety, 32 to 38 suggest moderate dental anxiety, and scores of 39 or above reflect high dental anxiety [42,65] (Table 5).
Table 5. Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS).

3.1.7. Dental Fear Schedule Subscale-Short Form (DFSS-SF)

Tool Definition: It is a shortened version of the original Dental Fear Schedule (DFS), designed to provide a faster, yet reliable and valid method of measuring dental fear [42,66].
Developed by Foláyan et al. (2003) [67].
Tool validation and reliability: The DFSS-SF was validated for children aged 8 to 13 years, demonstrating internal consistency (α = 0.82) and test–retest reliability (r = 0.73). Criterion validity was supported by a correlation with the Frankl Behavior Rating Scale (r = −0.54), with higher scores in anxious children (mean = 23) compared to non-anxious children (mean = 18.7) [67].
Target population: The DFSS-SF is specifically used to assess dental anxiety in children [66]. It was validated by Folayan et al. (2003) and was used mainly with children aged 8 to 13 years [67].
Scoring: It evaluates fear levels across various dental situations through a 5-point Likert scale, where 1 represents “not afraid” and 5 represents “very afraid. The scale includes 12 items: making a dental appointment, walking into the dental office, sitting in the waiting room, seeing dental instruments, hearing the drill, seeing the drill, feeling the vibration of the drill, seeing the injection needle, feeling the injection needle, smelling dental chemicals, undergoing an oral examination, and overall fear of dental treatment. Each response is scored, and the sum of all item scores indicates the child’s overall level of dental fear; higher scores reflect greater anxiety [66] (Table 6).
Table 6. Dental Fear Schedule Subscale-Short Form (DFSS-SF).

3.1.8. Smiley Faces Program (SFP)

Tool Definition: is a computerized tool designed to assess dental fear and anxiety (DFA) in children [65,68].
Developed by Buchanan in 2005 [68].
Tool validation and reliability: The SFP was validated for children aged 6 to 15 years, demonstrating internal consistency (α = 0.80) and test–retest reliability (r = 0.80). Concurrent validity was supported by correlations with the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) (r = 0.60) and the Modified Child Dental Anxiety Scale (MCDAS) (r = 0.60). Construct validity was indicated by higher anxiety ratings for invasive procedures (drill and local anesthetic) compared with waiting room and pre-visit situations [68].
Target population: Based on the Modified Dental Anxiety Scale (MDAS), the SFP is intended for children aged 6 to 15 years [65,68].
Scoring: This interactive tool uses a seven-point animated faces response scale, where children adjust a neutral face to appear happier or sadder according to their anxiety level. The assessment consists of four items, asking children about their feelings toward: having to go to the dentist the next day for treatment, sitting in the waiting room before a dental appointment, having a tooth drilled, and receiving a local anesthetic injection. Children respond on a scale from 1 to 7, where 1 represents “very happy” (no anxiety) and 7 indicates “extremely sad or nauseous from anxiety.” The total score ranges from 4 (no DFA) to 28 (most severe DFA), providing a reliable and valid measure of dental anxiety in children [65,68]. The responses the children gave were: 1 = Very happy (no anxiety), 2 = Slightly happy, 3 = Neutral, 4 = Slightly sad, 5 = Sad, 6 = Very sad, 7 = Extremely sad/nauseous from anxiety.

3.1.9. Revised Smiley Faces Program (SFP-R)

Tool Definition: is a computerized tool designed to assess dental fear and anxiety (DFA) in children. It was developed as an improvement on the original Smiley Faces Program (SFP).
Developed by Buchanan in 2005 (2010) [69].
Tool validation and reliability: The SFP-R was validated for children aged 4 to 11 years, demonstrating internal consistency (α = 0.70) and test–retest reliability (r = 0.80). Concurrent validity was supported by a correlation with the MCDAS (r = 0.60), and construct validity was indicated by higher scores in girls and older children [69].
Target population: It is a computerized dental anxiety measure for children aged 4 to 11 years [69].
Scoring: The SFP-R includes an additional item about tooth extraction and an updated animated faces response set, based on child input during small-scale pilot studies. The program is designed using interactive graphics to measure dental fear and anxiety (DFA). Scores for the SFP-R range from 5 (no DFA) to 35 (most severe DFA) [42].

3.1.10. Facial Image Scale (FIS)

Tool Definition: It is a simple, pictorial self-report measure designed to assess dental anxiety in children.
Developed by Buchanan and Niven in 2002 [53].
Tool validation and reliability: According to Buchanan and Niven (2002) [53], the Facial Image Scale (FIS) in children aged 3 to 18 years showed low mean scores (2.2) and no significant effects of age or gender. Concurrent validity was supported through correlation with the Venham Picture Scale (VPS) (r = 0.70, p < 0.001) [53].
Target population: The scale is designed for children and adolescents aged 3 to 18 years [53].
Scoring: The FIS consists of five facial images, ranging from a very happy face to a very unhappy face, illustrating different anxiety levels. Each face is assigned a score from 1 (very happy, no anxiety) to 5 (very unhappy, extreme anxiety). The total score provides an indication of dental anxiety, with higher scores reflecting greater fear [53] (Figure 2).
Figure 2. Facial Image Scale (FIS).

3.1.11. Abeer Children’s Dental Anxiety Scale (ACDAS)

Tool Definition: It is a scale designed to measure dental anxiety in children.
Developed by Al-Namankany et al. in 2012 [70].
Tool validation and reliability: The ACDAS was validated for children aged 6 years and above, showing internal consistency (α = 0.90) and test–retest reliability (κ = 0.88–0.90). Concurrent validity was supported by correlation with the CFSS-DS (r = 0.77), and a cutoff score > 26 indicated anxiety (sensitivity 96%, specificity 66%). It is also validated in Arabic, Turkish, Malay, and Spanish [71,72,73,74].
Target population: This scale was specifically designed for children and adolescents aged six and older.
Scoring: The questionnaire consisted of three parts. Part A consists of 13 self-reported questions, arranged in logical order, that ask about the child’s feelings when facing dental experiences. Each question used a 3-face response set. Face 1 represented the feeling of a relaxed, not scared, “happy” person. Face 2 represented a neutral/fair feeling of being “OK.” Face 3 represents the anxious feeling of being “scared.” The child was asked to check under the face that best described his or her response to the question, and a number (1, 2, or 3) was assigned accordingly. The range of values was, therefore, from 13 to 39. The scale indicates that the child is anxious if the score is 26 or higher. 2. Part B comprised three self-reported questions that asked about the child’s feelings of shyness regarding the dentist, or the way his/her teeth looked, and worry about losing control at the dentist; afforded a cognitive assessment; and each required “yes” or “no” as a response. 3. Part C consisted of 3 questions for further assessment of the child, as reported by the legal guardian (to report if the child had a previous experience and how the legal guardian expected his/her child to behave prior to the start of the treatment). The third question was for the dentist to report the child’s behavior at the end of the visit; each question required “yes” or “no” as a response [70] (Figure 3).
Figure 3. Abeer Children’s Dental Anxiety Scale (ACDAS).

3.1.12. Children’s Experiences of Dental Anxiety Measure (CEDAM)

Tool Definition: is a child-centered questionnaire designed to assess dental fear and anxiety.
Developed by Porritt et al. in 2018 [75].
Tool validation and reliability: The CEDAM-14 was validated for children aged 9 to 16 years, demonstrating internal consistency (α = 0.88) and test–retest reliability (ICC = 0.98). Rasch analysis confirmed a unidimensional 14-item structure without age or gender bias. Construct validity was supported by higher scores in clinically anxious children, while concurrent validity was demonstrated through a correlation with the Modified Child Dental Anxiety Scale (MCDAS) (Spearman’s r = 0.67). The CEDAM-14 was also responsive to change, detecting reductions in anxiety after CBT intervention (Cohen’s d = 1.39) [75]. It has additionally been validated in Portuguese and Iranian populations [76,77].
Target population: The CEDAM is validated for use in children aged 9 to 16 years.
Scoring: The CEDAM consists of 14 items, rated on a three-point scale, with total scores ranging from 14 to 42, with higher scores indicating greater dental anxiety. A manual conversion table transforms raw scores into an interval scale, enhancing precision in clinical and research applications [75] (Table 7).
Table 7. Children’s Experiences of Dental Anxiety Measure (CEDAM).

3.1.13. Shortened Children’s Experiences of Dental Anxiety Measure (CEDAM-8)

Tool Definition: The CEDAM-8 is a shortened version of the Children’s Experiences of Dental Anxiety Measure (CEDAM-14), designed to enhance feasibility in clinical and research settings.
Shortened CEDAM (CEDAM-8).
Developed by Porritt et al. in 2021 [78].
Tool validation and reliability: The CEDAM-8 was validated for children aged 9 to 16 years, showing internal consistency (α = 0.86) with no floor or ceiling effects. Criterion validity was supported by correlation with the CEDAM-14 (r = 0.90), while construct validity was supported by correlation with the global dental anxiety item (r = 0.77). The CEDAM-8 was also responsive to change, detecting meaningful improvement [78].
Scoring: The CEDAM-8 consists of eight items, each rated on a three-point scale, where 0 = Not at all like me, 1 = A bit like me, and 2 = A lot like me. The total score ranges from 0 to 16, with higher scores indicating greater levels of dental anxiety [78] (Table 8).
Table 8. Shortened Children’s Experiences of Dental Anxiety Measure (CEDAM-8).

3.2. Objective Measurements of DFA

Dental patients typically receive recommendations for treatment modalities based on the clinician’s objective assessment, which may involve behavioral management alone, inhalation sedation, intravenous sedation, or general anesthesia [79].
Objective assessments are especially valuable in situations where patients may not provide accurate reports of their anxiety levels due to denial, insufficient self-awareness, or difficulty in communicating.

3.2.1. Venham’s Clinical Anxiety Rating Scale (VCARS)—(Observational Measurement)

Tool Definition: The Venham Clinical Anxiety Rating Scale (VCARS) is an objective behavioral measure designed to assess dental anxiety in children undergoing dental treatment [19].
Developed by Venham et al. in 1977 [19].
Tool validation and reliability: According to Venham et al. (1980), the VCARS was validated in preschool children aged 2 to 5 years, showing high inter-rater reliability (r = 0.78–0.98) and construct validity through significant score differences across sequential visits, and by comparison with physiological measures (heart rate) and the Venham Picture Scale (VPS) [80].
Target population: The target population for VARS is generally children aged 3 to 12 years [80].
Scoring: VARS is constructed of six behaviorally defined categories that range from 0 to 5, with a higher score indicating a higher amount of anxiety. The score gradually increases from relaxed, smiling, willing, and able to converse (Score 0), to the child is totally out of control (Score 5) (Table 9).
Table 9. Venham Clinical Anxiety Rating Scale (VCARS).

3.2.2. Heart Rate Monitoring (Physiological Measurement)

Increased heart rate is a typical physiological response to anxiety [81]. Measuring heart rate in beats per minute (bmp) during dental visits can offer an objective evaluation of a patient’s level of fear and anxiety. Heart rate monitors and pulse oximeters are used to measure changes in heart rate in response to dental treatment. Elevated heart rate can serve as an indicator of heightened anxiety, thus necessitating the implementation of measures to manage anxiety. It is a safe, non-invasive method that is converted to a numerical score by applying age-specific thresholds. Accurate reference ranges are key to assessing whether a vital sign is abnormal [82]. However, it is not constant, and although in a specific range, it varies between children. Thus, to assess anxiety, two to three measurements are required (before, during, and after the procedure). According to studies, Heart Rate (HR) monitoring was validated in children aged 6 to 12 years, with mean values ranging from 80 to 118 bpm. Validity was supported by correlations with the Corah Dental Anxiety Scale (r = 0.57) and the numeric Visual Facial Anxiety Scale (rs = 0.48) [15,83].

3.2.3. Blood Pressure (Physiological Measurement)

Blood pressure is a useful physiological indicator for evaluating dental anxiety and stress; elevated blood pressure during dental treatment may reflect the patient’s emotional discomfort and anxiety in the clinical environment [84]. Multiple studies found that the increase in blood pressure (BP) correlates with a significant increase in dental anxiety during extraction and local anesthesia [85,86]. The measurement of blood pressure (BP) is usually recorded 5 min before the dental procedure as a baseline, during the dental procedure, and post-procedure to track normalization. According to studies, Blood Pressure (BP) monitoring was validated in children aged 8 to 12 years, with a mean systolic pressure of 125.0 ± 9.4 mmHg and a mean diastolic pressure of 79.9 ± 5.7 mmHg. Validity was supported by a positive correlation between systolic BP and the numeric Visual Facial Anxiety Scale (rs = 0.29), while diastolic BP showed no significant correlation [15].

3.2.4. Salivary Cortisol Levels (Physiological Measurement)

Saliva is widely recognized as a valuable diagnostic tool in healthcare. Due to its non-invasive collection method and diverse composition, it is well-suited for evaluating biomarkers associated with different illnesses [87]. Salivary diagnostics have the potential to detect diseases early, track their progression, and provide individualized treatment options, which could significantly change current healthcare practices [87].
Cortisol, also referred to as the stress hormone, is an essential hormone that is secreted by the adrenal glands in response to stress. It plays a vital role in regulating the body’s stress response and influencing multiple physiological systems. Cortisol levels vary throughout the day, but continuous or extreme stress can result in chronically increased levels, which can have adverse consequences on both physical and mental well-being [88,89]. Salivary Cortisol was validated for children from birth to 14 years of age [87,89]. Salivary cortisol is a reliable indicator of physiological stress due to its association with the Hypothalamic–Pituitary–Adrenal (HPA) axis activity; it is a non-invasive method for children and has the ability to distinguish between children with and without anxiety [90].
The collection methods:
Unsimulated method: This method can be achieved by instructing the individual to allow saliva to accumulate naturally in their mouth before expelling it into a sterile vial or collection tube, ensuring that they avoid swallowing during the process. Alternatively, the Salivette kit instructs the individual to place a sterile cotton swab from the Salivette kit under their tongue or between their gum and cheek without chewing. After approximately two minutes, the cotton swab is removed and placed into the collection tube for subsequent analysis.
The simulated method involves instructing the participant to chew on a sterile cotton swab from the Salivette kit for approximately 1–2 min, stimulating saliva production and saturating the swab. Once adequately saturated, the swab is placed back into the collection tube provided. After saliva collection, the sample should be stored in a sub-zero freezer in order to preserve its integrity until the sample is analyzed using a specialized Enzyme-Linked Immunosorbent Assay (ELISA) [91].

3.2.5. Electrodermal Activity (Physiological Measurement)

Electrodermal Activity (EDA) measures the activation of sweat glands, which are solely under sympathetic nervous system control. It is a highly sensitive and somatically independent indicator of sympathetic arousal, making it a valuable tool for assessing the emotional and cognitive responses of children experiencing dental anxiety [84]. It is usually recorded by using an EDA sensor device, 3–5 min before the procedure, during the procedure, and 3 min after the procedure. Higher reading indicates dental anxiety.
EDA was validated for children aged 5 to 13 years and for children with developmental disabilities [92,93]. It also demonstrated reliable functional consistency across clinical settings, particularly in non-verbal and cognitively impaired populations [92,93,94].
Table 10 presents DFA tools along with their age ranges, questions and answers, scales and scoring, strengths, limitations, and notes on validity, reliability, and validated languages. It also reports the quality score of the DFA tools according to the PRO checklist. Supplement Table S1 reports the DFA quality scoring in more detail.
Table 10. Dental Fear and Anxiety Assessment Tools and Their Characteristics.
All the dental anxiety tools included a detailed explanation of their purpose and target audience. Each tool was developed by experts, and most of the questionnaires were brief and simple to use. In general, studies demonstrated consistent results when the measures were repeated, thus indicating good reliability. Additionally, the tools’ ability to distinguish between children with high anxiety and those with low anxiety, as well as their expected associations with other anxiety measures, provided evidence of their validity.
Despite these advantages, certain disadvantages were noticed. Except for the CEDAM and the CEDAM-8, the majority of the measures were not made to monitor change over time. The fact that none of the tools provided guidance on how to handle missing answers was another disadvantage (Supplement Table S1). Table 11 provides further details regarding each tool’s validity and reliability.
Table 11. Validity and reliability of DFA tools.

4. Discussion

Assessment tools for Dental Fear and Anxiety (DFA) are important for pediatric dentists to understand and utilize in their daily practice with their patients and in research. Given the numerous DFA tools available in the literature, which vary in complexity, subjectivity, and validation criteria, this review aims to provide a comprehensive summary of these tools in order to support pediatric dentists in their selection and application.
Subjective tools, although generally easier to use, measure anxiety based on the individual’s perception of their symptoms. Factors such as personal experience, cognitive ability, and maturity can influence the results, thereby potentially leading to reporting bias [64,95].
Moreover, the C-DAS and its modified versions, MDAS, offer a brief assessment; however, the need for verbal and cognitive ability limits the use of these tools. In addition, they are both limited in scope, measuring a narrow range of dental situations. The MCDAS and its facial version (MCDASf) are easy to use for children, due to the modification of the questions and the inclusion of faces, and, to a lesser extent, the VPS and FIS. Making them more suitable for younger children.
In contrast, the CFSS-DS and the DFSS-SF provide broader coverage of DFA situations. Still, the need for cognitive ability and the length of the tools remain obstacles to their practical use.
While the SFP and its revised version, SFP-R, are computerized tools that have been developed to enhance the child’s involvement through interactive visual methods, their cost and access to the tools remain a challenge in utilizing them on a broad scale for children, unlike the other tools.
Recent tools have been developed to measure DFA, such as the CEDAM and CEDAM-8, although these tools have demonstrated excellent psychometric properties; however, the length of the scales and the inability to use them with younger children remain significant limitations for the scales. ACDAS overcomes these obstacles by using short, simple questions and incorporating faces so as to facilitate straightforward answers, making it a suitable choice for use in the clinic.
Subjective tools are easy to administer, non-invasive, time-efficient, and offer good validity and reliability. They can be used in different settings with a wide range of children’s ages. Dentists can optimize their use by selecting tools based on the child’s age, literacy level, clinical context, and the purpose of the assessment.
Additionally, multiple studies have evaluated DFA using various tools on the same sample and found no statistically significant differences among them [70,96,97,98,99]. This suggests that their effectiveness in measuring DFA is comparable, allowing dentists flexibility in both clinical application and research. However, studies that utilized DFA tools to assess different behavior management techniques (BMTs) have reported varying outcomes. For example, Bagher et al. compared two types of BMTs and reported similar outcomes related to VCARS, ACDAS, and heart rate, with no significant differences between the techniques. However, salivary cortisol levels showed greater variation between the BMTs [100]. In addition, Khogeer et al. (2025) [101] assessed dental anxiety using FIS, VCARS, and heart rate. They found that changes in dental anxiety across different BMTs were not consistent. The self-reporting tool (FIS) demonstrated greater changes compared to evaluations conducted by an observer, such as the dentist (VCARS). Heart rate changes were greater than those measured by VCARS but less than those measured by FIS [101]. This could also indicate that a child’s self-perception may reflect preference more than actual anxiety. Thus, we recommend using multiple complementary assessment tools in order to achieve a more reliable evaluation of dental anxiety.
To date, there is no universally accepted gold standard for assessing DFA. Consequently, most studies establish criterion validity by comparing outcomes across instruments. In this review, we have summarized the comparisons in Table 11. Therefore, until a gold standard is established, triangulation using multiple validated tools and context-specific validation is recommended.
In addition, multiple DFA tools (CFSS-DS, MDAS, MCDAS, MCDASf, ACDAS, CE-DAM) have been employed across different populations. These tools were translated, validated through face and content validity, and pilot tested to ensure proper cultural adaptation. Moreover, observer-based ratings such as FIS and ACDAS incorporated either culturally neutral or locally relevant imagery and behavioral anchors. Finally, objective physiological measures, such as heart rate, should be interpreted relative to individual resting baselines and culture-specific normative ranges [82].
A notable limitation across all subjective tools is the lack of a strategy for handling missing data, which, if it occurs, could affect the questionnaire and result in measurement bias, jeopardizing the dentist’s decision-making and the choice of a proper treatment plan. It can be overcome by the dentist ensuring that the child answers all the questions and combining clinical judgment with the questionnaire [102].
On the other hand, objective tools do not require the child’s participation in answering questionnaires. It depends on observable symptoms, as examined by clinicians, or on measuring physiological changes [103]. It is particularly valuable for children who are very young or have a cognitive disability.
Venham Clinical Anxiety Rating Scale (VCARS) is a valuable tool for clinicians to use for children of all ages and cognitive states, due to its simplicity and clarity. However, examiners’ calibration and training are vital for using objective clinician evaluation.
Additionally, heart rate is often used to assess a patient’s anxiety by monitoring changes before, during, and after dental treatment. Studies have demonstrated variations in mean heart rate among children subjected to different behavior management techniques, such as Ask-Tell-Ask and Tell-Play-Do, compared to the traditional Tell-Show-Do method [103]. Heart rate is typically used in conjunction with other anxiety measurement approaches to provide a more comprehensive assessment [100,104]. However, a heart rate monitor requires a certain degree of cooperation from the child or assistance from the dental team to be used during the dental visit [105]. Additionally, it is influenced by the child’s level of activity, age, and can vary between genders [106]. It is also affected by the devices.
Moreover, measuring blood pressure is affordable, and the results are standardized, with minimal cooperation from the child. However, studies have shown that blood pressure ranges can vary based on a child’s age, gender, obesity, and geographic location, making it a challenging tool to be used as a reliable indicator for diagnosing anxiety in children [107,108]. Additionally, it lacks continuity of measurement and may be descriptive during dental treatment.
Salivary cortisol is a reasonable measure of anxiety due to its non-invasive method; however, the cost and time required to collect samples before, during, and after, make it impractical to use outside the research setting. Additionally, it has variable ranges and is influenced by multiple variables [106].
EDA is a valuable technique for evaluating DFA in children, where variations in skin conductance levels, influenced by sympathetic nervous system activity, act as physiological markers of anxiety or stress. It is non-invasive and sensitive to acute emotional arousal, making it beneficial for anxiety assessment during dental treatments. Still, it costs more than other tools and could cause discomfort to children during treatment.
While objective tools provide valuable psychological and behavioral data, their practical application is limited by the availability of resources across different settings. Tools like heart rate monitors and blood pressure devices are affordable and available in various clinical settings, unlike salivary cortisol and EDA, which are more challenging to obtain and are mostly used in research settings and specialized environments.
Despite considerable progress in scale development and techniques for identifying anxious children, there remains potential for innovation, particularly with advancements in technology and artificial intelligence that could support the detection and treatment of anxiety. However, the validation and reliability of these tools remain critical areas that require further evaluation and meta-analysis across different populations and age groups so as to have consistently more accurate measurement tools.

5. Conclusions

A wide range of valid and reliable tools are available to assess DFA in children. Selection should be tailored to the child’s age, cognitive abilities, clinical setting, and clinician training. This review serves as a practical reference to aid in evidence-based decision-making for DFA management in pediatric dentistry.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare13202597/s1.

Author Contributions

Conceptualization, M.B., and H.J.S.; methodology, M.B. and H.J.S.; software, M.B., M.A. and Y.T.A.; validation, M.B., M.A., Y.T.A., O.M.F. and H.J.S.; formal analysis, M.B. and H.J.S.; investigation, M.B., M.A. and Y.T.A.; resources, M.B., M.A. and Y.T.A.; data curation, M.B., M.A., Y.T.A., O.M.F. and H.J.S.; writing—original draft preparation, M.B.; writing—review and editing, M.B., M.A., Y.T.A. and H.J.S.; visualization, M.B. and H.J.S.; supervision, O.M.F. and H.J.S.; project administration, M.B., O.M.F. and H.J.S. All authors have read and agreed to the published version of the manuscript.

Funding

The project was funded by KAU Endowment (WAQF) at King Abdulaziz University, Jeddah, Saudi Arabia. The authors, therefore, acknowledge with thanks WAQF and the Deanship of Scientific Research (DSR) for technical and financial support.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

No new data was created or analyzed in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
DFADental fear and anxiety
VASVisual Analog Scale
C-DASCorah Dental Anxiety Scale
MDASModified Dental Anxiety Scale
MCDASModified Child Dental Anxiety Scale
MCDASfFaces version of the Modified Child Dental Anxiety Scale
VPSVenham Picture Scale
CFSS-DSChildren’s Fear Survey Schedule-Dental Subscale
DFSS-SFDental Fear Schedule Subscale-Short Form
SFPSmiley Faces Program
SFP-RRevised Smiley Faces Program
FISFacial Image Scale
ACDASAbeer Children’s Dental Anxiety Scale
CEDAMChildren’s Experiences of Dental Anxiety Measure
CEDAM-8Shortened Children’s Experiences of Dental Anxiety Measure
VCARSVenham’s Clinical Anxiety Rating Scale

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