Dental anxiety partially limits, or completely prevents, utilisation of oral health care services [1, 2]. It increases the prevalence of dental disease [2, 3]. Anxious persons present more damaged or missing teeth and less restored teeth [4]. Regular and conventional care is bypassed by dentally anxious persons, who rely on self-care, use of emergency services, and occasionally use of traditional or parallel remedies to relieve pain. The oral health and quality of life of this population are affected [5]. When professional care is provided, it is often given under general anaesthesia without consideration for the aetiological factors behind dental fear. Ideally, the management of patients with dental anxiety requires psycho-behavioural and sedation procedures [6, 7] as alternatives to general anaesthesia. Such techniques have been shown to improve patient capacity to cope with dental care over time [8]. These techniques, however, are not always included in undergraduate or postgraduate teaching in France.

The prevalence of dental anxiety has been shown to range between 4 and 20% in the general population of industrialised countries [9–11]. However, there are no available data for France. It is impossible to advocate for services for persons with dental anxiety without an idea of the numbers and types of persons affected. Special care for people with dental anxiety or phobia has a cost [12] and research studies are needed to support reorganisation of both dental teaching and dental services. This study aims to evaluate the prevalence, severity and associations of dental anxiety declared in a large sample of the French adult population and to analyse the impact of psychosocial variables on this anxiety.

This is the first national study evaluating the prevalence of dental anxiety in France. It gives an estimation of 13.5% of people with moderate or severe dental anxiety within a convenience sample of 2725 participants.

The main weakness of this study is the use of a convenience sample. This limits the degree to which the results can be assumed to represent the French population as a whole. The only difference found between the study group and the French population however, was in occupational category (p = 0.05) as there were more executives in the study group than in the general population (Figure 3). The study design was likely to exclude certain groups known to have a higher prevalence of dental fear, such as children, people with disabilities, elderly persons with dementia and those on the margins of society. This may lead to the hypothesis that dental anxiety was probably underestimated compared to the general population in the current study. Despite these limitations, the estimation is sufficiently high (13.5%) to justify advocacy for new strategies of care for the population with dental anxiety.

These results are similar to those of other industrialised countries in Europe [10], in North America [9], and in Australia [17] (10% to 18%), and is lower than other countries such as China (30%) [18]. In the current study, dental anxiety was related to both longer time since the last dental appointment and greater frequency of cancelled appointments. These results agree with the concept of avoidance of care proposed by Locker [2]. Other authors have associated these behaviours with previous negative experiences [19]. It has also been reported that presence of pain during treatment [20] and the negative attitude or unpleasant remarks of the dentist were correlated with dental anxiety [21].

This study underlines the need for prevention of dental anxiety. Dental anxiety often onsets in childhood [22–24] and young patients should consequently be the target for prevention. It has been shown that early education in children has a positive influence on dental anxiety, improving the long term dental follow-up [25]. This is particularly important as many children already have anxiety at their first contact with the dentist [26]. Although dental anxiety is highly correlated with state anxiety [27], it is often described by patients as an iatrogenic consequence of dental care [28]. This raises the problem of the responsibility of the dental profession and/or of the practitioner. Ethically, if not legally, the aggravation of dental anxiety after a dental episode undertaken without any preventive measures in an anxious patient could possibly be considered as resulting from professional fault. Education should thus be aimed at dental students and professionals. The development of dental anxiety could be prevented with pain control, behaviour management, consideration of the patient as a whole and/or if necessary access to sedation. The inclusion of behavioural sciences in dental education and the integration of ethical considerations in the academic dental curriculum could help to improve the situation [29, 30]. For example, French university requirements for the clinical evaluation of dental students are often based on quantitative criteria, such as number of patients treated, or number of teeth restored. Such criteria encourage students to think in terms of quantity but not quality, and are thus incompatible with the principles of avoidance of harm defined by biomedical ethics. This is of particular concern in relation to the treatment of children [31, 32]. In addition, conscious sedation is not taught to undergraduates in France.

This study could also be useful to support the development of access centres for persons with dental fear. Deconditionning dental fear needs a multidisciplinary team and is time consuming. Training and rehabilitation seem possible in a favourable environment [33, 34]. In Northern Europe [35, 36], specific units with multidisciplinary competence and defined protocols allow access to prevention and treatment for anxious patients. In France there are no such teams, although behaviour management and sedation techniques are being developed [8, 37]. Moreover, dental anxiety is generally considered as a fatality rather than a disease, despite definition of the different categories of dental anxiety derived from the DSM-IV psychiatric criteria [38]. As a consequence there is no motivation for the development of services. In addition, for the patients able to access one of the few centres treating both dental fear and dental disease, the financial costs of treatment are not recognised by the social security system. This situation increases inequalities in oral health for people with dental anxiety.

Dental anxiety in France appears to concern a similar proportion of the population as in other industrialised European, Australasian or North American countries. Recommendations for prevention and management of dental anxiety are made with reference to dental education and health care services in France.