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An artificial-intelligence-based Service
quality in
method for assessing service prosthodontics
sector
quality: insights from the
prosthodontics sector 291
Sara M. Martins Received 10 May 2019
Revised 18 September 2019
ISCTE Business School, University Institute of Lisbon, Lisbon, Portugal 8 January 2020
Fernando A.F. Ferreira 21 January 2020
Accepted 22 January 2020
ISCTE Business School, BRU-IUL, University Institute of Lisbon, Lisbon, Portugal
and
Fogelman College of Business and Economics, University of Memphis, Memphis,
Tennessee, USA
Jo~ao J. M. Ferreira
NECE Research Unit, University of Beira Interior, Covilh~a, Portugal, and
Carla S.E. Marques
CETRAD Research Unit, DESG-ECHS, University of Tras-os-Montes e Alto Douro,
Vila Real, Portugal

Abstract
Purpose – The prosthodontics sector is facing major challenges because of scientific and technological
advances that imply a clearer definition of lines of action and decision making processes. Measuring quality of
service in this sector is a complex decision problem since the perceptions of three main players need to be
considered: patients, dentists and dental technicians. This study sought to develop an artificial-intelligence-
based (AI-based) method for assessing service quality in the dental prosthesis sector.
Design/methodology/approach – Using strategic options development and analysis (SODA), which is
grounded on cognitive mapping, and the measuring attractiveness by a categorical based evaluation technique
(MACBETH), a constructivist decision support system was designed to facilitate the assessment of service quality
in the dental prosthesis sector. The system was tested, and the results were validated both by the members of
an expert panel and by the vice-president of the Portuguese association of dental prosthesis technicians.
Findings – The methodological process developed in this study is extremely versatile and its practical
application facilitated the development of an empirically robust evaluation model in this study context.
Specifically, the profile analyses carried out in actual clinics allowed the cases in which improvements are
needed to be identified.
Originality/value – Although already applied in the fields of AI and decision making, no prior work reporting
the use of SODA and MACBETH for assessing service quality in the prosthodontics sector has been found.
Keywords Artificial intelligence, Cognitive mapping, Healthcare service quality, MACBETH approach,
Problem structuring methods, Prosthodontics sector, SODA methodology
Paper type Research paper

1. Introduction
Dental prosthetics is the branch of dentistry that deals with the replacement of lost or absent
dental and gingival structures in order to restore patients’ form, function, aesthetics and oral

We wish to acknowledge the contribution and limitless willingness of the following expert panel
members: Alexandre Goul~ao, Ana Mexia, Edite Reis, Elizabete Antunes, Jo~ao Carlos Roque, Jo~ao Journal of Service Management
Vol. 31 No. 2, 2020
Carrasco and Monica Lucena. We are also grateful to Jose Ribeiro – vice-president of the Portuguese pp. 291-312
Association of Dental Prosthesis Technicians – for his extraordinary contribution and useful insights © Emerald Publishing Limited
1757-5818
during the consolidation session. DOI 10.1108/JOSM-03-2019-0084
JOSM health. It also offers advance training in the handling of complicated dental procedures (Yu
31,2 et al., 2013).
The dental prosthetics – or prosthodontics – sector has changed over time as a result of
regulations and technological innovations (Balshi et al., 2007; Bassi et al., 2013; Jonathan et al.,
2014). It is estimated that billions of dollars are expended on prosthodontics care worldwide
(cf. Bassi et al., 2013), which justifies, in part, the importance of this industry to countries’
economies. The importance of this sector is further justified by a wide range of different
292 reasons, such as: (1) the absence of dental structures has serious consequences, for people’s
physical and mental health (Reissmann et al., 2011), primarily because the chewing capability
is compromised, contributing to an alteration of feeding habits and the avoidance of the
ingestion of foods that are nutritionally important; (2) from a psychological point of view,
interpersonal relationships are affected (Reisine et al., 1989), promoting the isolation of people
who suffer from a lack of teeth; and (3) from a social point of view, the search for a job, for
example, is also conditioned by the lack of appearance and care represented by the absence of
teeth. In this sense, daily oral hygiene practices are advised and should be widely
implemented with the aim of contributing to good health and delaying, as much as possible,
the early loss of teeth (Nakano et al., 2008).
In this context, the need to recognize dental technicians as key members of oral health
teams has never been more evident. In addition, patients are now better informed about both
available prosthetic options and the healthcare services they receive, reinforcing the need for
cooperation between the health professionals involved (Habbal, 2011). Currently, individuals
are increasingly concerned about both looking good and quality of life (Nakano et al., 2008; Yu
et al., 2013; Anwar et al., 2015), so any rehabilitation of lost dental structures needs to take into
account all assessment criteria that lead to good results. However, this requires a detailed
analysis of the quality of services provided in the prosthodontics sector (Reisine et al., 1989;
Alghazzawi, 2016).
The manufacturing of dental pieces implies that the professionals involved have to have
great skill and extensive knowledge since these pieces are unique and differentiated
according to each patient’s needs (i.e. there are no economies of scale in this industry). The
processes of service quality evaluation are thus particularly critical in the field of dental
prosthesis. Although several hundred articles have already focused on the quality of services
in healthcare provision, the existing literature on this topic in the prosthodontics sector is
quite reduced (cf. Seth et al., 2005; Bassi et al., 2013). The scarcity of evaluation instruments –
or even their absence – underlines the importance of both our proposal and the present
study’s theoretical and practical contributions.
This research, therefore, sought to develop a multiple-criteria evaluation system to assess
service quality in the prosthodontics sector. The current study was based both on a
constructivist framework and on a logic of complementarity, highlighting the active role of
experts in this sector, who constitute an asset in the search for a realistic evaluation system.
Because it is known that the performance of most operation systems is significantly affected
by the interaction of human decision makers (cf. Robinson et al., 2017), a methodology based
on the use of artificial-intelligence (AI) techniques holds great potential in the assessment of
service quality in the dental prosthesis sector (see also Dewhurst and Gwinnett, 1990;
Badinelli et al., 2012; Pe~ na-Siles et al., 2012).
To operationalize this research, an expert panel in quality of dental prosthesis services
was formed. In the first phase, the strategic options development and analysis (SODA)
methodology was applied, using cognitive maps to identify the assessment criteria to be
included in the evaluation model. As pointed out by Ormerod (2018, p. 1370), “SODA elicits
the subjective views of participants and subjects them to some logical analysis (for instance,
the analysis of cognitive maps)”. In the second phase, we employed the measuring
attractiveness by a categorical based evaluation technique (MACBETH), which facilitated
the calculation of the model weights. Although already applied in the fields of AI and decision Service
making (cf. Bana e Costa et al., 2016), no evidence was found in the literature reporting the quality in
integrated combination of these methodologies in this study context, allowing our proposal to
contribute to the extant literature on service quality evaluation and operational research/
prosthodontics
management science (OR/MS). The face-to-face group sessions lasted 4 h each time, and the sector
group of experts comprised seven decision makers (i.e. three dental prosthesis technicians,
two dentists and two patients). The aim was to acquire a better knowledge of both current
evaluation practices and existing limitations regarding service quality in the prosthodontics 293
sector.
The remainder of this paper is organized as follows. The second section provides an
overview of the literature on service quality in the prosthodontics sector. Section 3 introduces
the methodology and relevant epistemological aspects. Section 4 describes the processes
followed to construct and test the proposed evaluation system. The final section presents the
study’s conclusions and lays out a roadmap for further research.

2. Literature review
When lost dental structures can no longer be restored, the use of dental prostheses is
essential to recovering both the aesthetics and functions of lost teeth, avoiding negative
consequences for the remaining structures due to excessive loads (Gilbert et al., 2004; Bassi
et al., 2013). According to Paravantis and Chitiris (2009) and Reissmann et al. (2011),
prosthetic treatments produce significant improvements in patients’ health, and the use of
proper laboratory materials and techniques facilitates the successful replacement of lost
dental structures. As reported by Chen et al. (2015), the success of this process naturally
varies from case to case and individual to individual, as well as according to the choice of
techniques and materials.
Economic aspects are decisive in the choice of material (MacEntee and Walton, 1998;
Habbal, 2011) and the technique used for each prosthesis (Jonathan et al., 2014). However,
with recent technological developments and the influence of marketing, patients are better
informed about the options available in the market, reinforcing the need for various choices
to be made with their dentist (Marchack, 1995; Priest and Priest, 2004; Probst et al., 2012). In
this way, dentists play a fundamental role by advising their patients of both advantages
and disadvantages inherent to their choice of dental prostheses (Rich, 2002; Naumova
et al., 2017).
A wide range of articles have addressed quality of service in healthcare provision (for a
review, see McColl-Kennedy et al., 2017). However, regarding the prosthodontics sector in
particular, the literature is still quite limited (cf. Seth et al., 2005; Bassi et al., 2013). Most of the
existing contributions have focused primarily on products. Table 1 presents summaries of
some relevant studies of service quality evaluation, emphasizing their contributions and
limitations. Notably, not all these authors have focused on the dental prosthetics sector,
underlining that studies focused on this sector are really quite scarce (for further discussion,
see also Parasuraman et al., 1988a and 1988b; Bassi et al., 2013).
In broad terms, quality is defined as the ability to manage resources effectively and
efficiently, satisfying all stakeholders in the process (Ferreira et al., 2017). Quality is usually
customer-oriented (cf. Tyrpak, 2015), but in the prosthodontics sector three main players are
involved, namely: dental prosthesis technicians, dentists and end users of prostheses (i.e.
patients) (Chamberlain et al., 1984). Quality of service in this area of health care thus needs to
be treated as a complex decision problem (Phillips et al., 2015; Yerdavletova and
Mukhambetov, 2015).
Measurement of various dimensions of service quality in dental prosthetics is a topic with
great potential but, as of yet, little explored, even though this evaluation process could be
JOSM Author Contributions
31,2
Overton and (1) Identified essential evaluation criteria
Bramblett (1972) to assess service quality in the
prosthodontics area
Parasuraman (1) Conducted research according to a
et al. (1985) model based on service quality gaps
294
Teas (1994) (1) Suggested two perspectives on
satisfaction with quality: quality of
care and quality of service
(2) Proposed alternative models of service
quality (i.e. evaluation
and performance of quality standards)
Parasuraman (1) Developed three alternative formats of
et al. (1994) questionnaire
(2) Emphasized the tendency of
customers to exaggerate in direct
evaluations
(3) Developed a clearer understanding of
correlations between SERVQUAL
dimensions and removal of overlays
Paul (2003) (1) Recommended the use of the
SERVPERF model over SERVQUAL
to measure quality of service in the
prosthodontics sector
Carlsson (2009) (1) Conducted an extensive review of
beliefs in the prosthodontics sector,
researching the scientific evidence
that supports them and elaborating
guidelines that could offer greater
quality and safety to patients
Ferreira et al. (1) Recommended a multicriteria
(2014) approach to evaluating quality of
service
Table 1. Longaray et al. (1) Defended problem structuring using
Models of quality of (2016) the multiple-criteria decision analysis
service evaluation: (MCDA) approach to support
contributions and decision making in health
limitations management
Limitations
(1) Quantitative data were not enough to
validate the criteria under discussion
(1) Obvious differences were found
between perceived quality of service
management and level of service
provided to consumers. These were
called “gaps” and they could restrict
evaluations of quality of service
(1) Difficulties arose in understanding
the reason for variations in
expectations during the evaluation of
the SERVQUAL approach
(1) Limitations were associated with
how service organizations should
apply measures for both provided
and expected services
(1) The sample was too small, and it
focused on a single geographical area
(1) The authors did not explain how they
developed the set of beliefs in
question
(1) The results were limited to a specific
sector
(1) The analyses were restricted to some
research platforms, thereby
narrowing the study’s scope

useful to clients and laboratory managers. Public entities who monitor the quality of services
provided to patients could also benefit. Satisfying the need for comprehensive and
well-informed evaluation procedures is likely an essential condition to improving service
quality in the sector, including regulating technician certification.
It is worth noting, however, that some of the limitations identified may impede proper
service quality evaluations. Ferreira et al. (2017, p. 454) note that “controversy continues to
persist regarding the methodology for evaluating service quality due to the intangible/
subjective nature [of this concept]”. This is why the choice of OR/MS methods and
techniques in the present study sought to maximize the clarity with which both assessment
criteria and their weights are defined. Although no approach is free of limitations, the
combined use of AI and decision making techniques, such as cognitive mapping and MCDA
methodologies, appeared promising with regard to the evaluation of service quality in the Service
dental prosthetics sector. quality in
prosthodontics
3. Epistemological and methodological background sector
In general, AI and decision support models are based on one of two epistemological
approaches: soft and hard (Bana e Costa et al., 1999; Belton and Stewart, 2002). The soft
approach begins in similar ways as the hard approach but differs from the latter in its ability 295
to search for constructivist solutions in which uncertainty is accepted (Ackermann, 2019;
Harwood, 2019; Lowe and Yearworth, 2019). The soft approach includes paying close
attention to the value system of decision makers (Ormerod, 2019). Table 2 presents some of
the characteristics of the soft paradigm.
Given these benefits, the process of structuring decision problems should be guided by
this soft paradigm, as this is a crucial stage of decision making. According to Bana e Costa
et al. (1999, p. 316), “the process is much more a freethinking oriented discussion forum for the
creation of new intervention opportunities than a technical act of solving a decision making
problem”. Thus, decision making processes apparently need to be divided into three stages
(cf. Bana e Costa et al., 2001; Ackermann, 2019):
(1) Structuring decision problems by objectives and focusing on the characteristics of
choice alternatives in order to build a more or less formalized model;
(2) Evaluating, which presupposes the determination of the alternatives’ impact on each
fundamental point of view (FPV);
(3) Elaborating recommendations.
According to Ferreira (2011, p. 102), “the construction of a model that intends to reflect the
stages of the decision support process and their interactions should be based on a clear
balance that expresses utility and realism”. Because the present study integrated cognitive
mapping and MACBETH, the resulting evaluation system became constructivist in nature,
as well as assuming a process-oriented stance (for further discussion, see Belton and Stewart,
2002; Bell and Morse, 2013; Ferreira et al., 2016a).

3.1 Complex decision problems and cognitive mapping

The present study was thus constructivist in nature and based on a logic of complementarity,
giving experts in the dental prosthetics sector an active role and thereby providing added

Characteristics Implications for decision-making process

Nonoptimization The search for an optimal solution is replaced by a solution made up of

compromises in different dimensions
Reduced need for data Solutions are formulated through the extensive interaction between quantitative
data, qualitative data and subjective judgments
Simplicity and This approach facilitates an understanding of problems and makes conflicts in
transparency different situations clearer
Inclusion of human People become active subjects in the processes supporting decision-making
factors
Bottom-up planning The necessary conditions for planning are created by moving from particular to
general aspects
Acceptance of This approach seeks to leave options open that could guarantee the flexibility Table 2.
uncertainty needed to deal with future events Characteristics of soft
Source(s): Ferreira (2011, p. 100) paradigm of OR/MS
JOSM value in the search for a more realistic evaluation system. The SODA approach applied was
31,2 developed by Eden and Ackermann (2004) to help decision makers and facilitators structure
complex decision problems with the use of cognitive maps. According to Eden (1992, p. 261),
“cognitive maps have an ability to describe, simulate, or predict thinking [that] is clearly
problematic”.
From an operational perspective, cognitive maps are seen as networks of ideas (i.e.
constructs, concepts or nodes) linked by arrows. The main objective of these maps is “to
296 portray, in the best way possible, the [participants’] ideas (as well as the objectives, feelings,
values and attitudes of the actors), in order to enable further analysis” (Ferreira, 2011, p.
132). In addition, according to Martins et al. (2015, p. 312), “the SODA method is
characterized by: (1) the ability to deal with qualitative factors; (2) the ability to structure
difficult [to analyze decision] situations; (3) the provision of support for group work; and (4)
[the quality of] being of great use in the development and implementation of strategic
directions”. This reinforces the importance of the negotiation process established between
process facilitators and decision makers (for further discussion, see also Tegarden and
Sheetz, 2003).
In order to operationalize the stages of the decision making process and integrate the
SODA approach into the structuring of complex decision problems, fundamental points of
view (FPsV) need to be developed. According to Ferreira (2011), these FPsV link the existing
interconnections and incompatibilities between the subsystem of actors and subsystem of
alternatives/actions. In addition, a tree of FPsV needs to be constructed. However, although
this tree is an important tool for structuring decision support processes, it should not be seen
as a final goal. To give greater depth to FPsV, they must also be operationalized by using
descriptors (see Figure 1).

3.2 MACBETH approach

MACBETH was developed by Bana e Costa and Vansnick (1995, 1997) in the early 1990s.
This approach facilitates the expression of “the intensity of preference that decision makers
have concerning the actions under analysis concretized through the expression of absolute
judgments of value difference (attractiveness) among actions” (Ferreira, 2011, p. 192). A
scale can thus be built based on participants’ value judgments. This approach is guided by
a constructivist conviction, involving strong interactivity in the construction of a numerical
scale and allowing semantic judgments of differences of attractiveness to be quantified (cf.
Ferreira and Santos, 2019). Canas et al. (2015, p. 371) state that “this approach allows
cardinal scales to be constructed and differences of attractiveness between choice
alternatives to be measured based on the decision-maker’s value judgments. It follows the
MCDA constructivist conviction and holds great potential in the definition of trade-offs
between evaluation criteria”.

Fundamental
Cognitive
points of
maps
view

Figure 1.
Cyclical process of Descriptors
structuring
Source(s): Bana e Costa et al. (1999, p. 317)
 Mathematically, MACBETH involves numerical representations of semi-orders for Service
multiple thresholds (Ferreira, 2011) based on the mathematical principles of Doignon (1984). quality in
These determine that, for each point of view (PVj), a structure of m binary relations (P(1), . . . ,
P(k), . . . , P(m)) exists in which P(k) is a preference relationship that grows stronger as k becomes
prosthodontics
greater. Ferreira (2011, p. 194) explains that: “the numerical coding rule proposed by the sector
MACBETH methodology consists of associating each action ∈ X with a real number v(a) such
that the differences v(a) – v(b), with aPb, are as compatible as possible with the judgments of
difference of attractiveness issued by the decision maker(s)”. 297
In order to define the intervals between consecutive categories of difference of
attractiveness, decision makers must define the categories’ Sk limits, which can be
considered transition thresholds (Almeida et al., 2015). Based on this reasoning, multiple semi-
orders with constant thresholds can be easily created as long as preferences are represented
by a function value v, with the Sk thresholds determined by applying formula (1):
aP ðkÞ b : Sk < vðaÞ  vðbÞ < Skþ1 (1)

Because the Sk thresholds are positive real constants, the intervals between semantic categories
of difference of attractiveness can be defined, in which, between the origin (i.e. S1 5 0) and Sm,
an infinite number of thresholds and categories exist. According to Bana e Costa and Vansnick
(1997), most decision makers can only perceive differences of attractiveness without defined
scales of intervals, so cardinal value scales for perceptions need to be built and represented by
using the semantic categories of attractiveness presented in Table 3.
Bana e Costa and Vansnick (1995) also found that a set of categories of difference of
attractiveness must be limited on the left by a “zero”. This way, given a P(m) b, another real or
fictional action c can always be introduced by the addition of one more level of impact,
showing that c is preferable to b more than a is preferable to b (Ferreira, 2011). Despite the
improvements made, the MACBETH approach has remained true to its initial conception,
interconnecting humanistic, interactive and constructivist aspects.
To ensure the consistency of judgments, cardinal value scales must be developed with
measurement rules based on formulas (2) and (3), which represent ordinal and semantic
conditions, respectively (Martins et al., 2015):
∀a; b ∈ X : vðaÞ > vðbÞ5aPb (2)

∀k; k* ∈ f1; 2; 3; 4; 5; 6g; ∀a; b; c; d ∈ X with ða; bÞ ∈ Ck

(3)
and ðc; dÞ ∈ Ck* : k ≥ K * þ 10vðaÞ  vðbÞ ≥ vðcÞ ¼ −vðdÞ
After verifying the consistency of judgments, linear programming is applied using formula
(4) (cf. Junior, 2008; Ferreira et al., 2012), which creates an initial scale to be discussed by
decision makers:

Category Difference of attractiveness

C0 Null
C1 Very low
C2 Low
C3 Moderate
C4 Strong Table 3.
C5 Very strong Semantic categories of
C6 Extreme difference of
Source(s): Adapted from Bana e Costa and Vansnick (1995) attractiveness
JOSM Min vðnÞ
S:T: : ∀a; b ∈ X : aPb0vðaÞ ≥ vðbÞ þ 1
31,2
∀a; b ∈ X : aIb0vðaÞ ¼ vðbÞ
∀ða; bÞ; ðc; dÞ ∈ X ; if the difference of attractiveness between
a and b is bigger than between c and d; then :
vðaÞ  vðbÞ ≥ vðcÞ  vðdÞ þ 1 þ δða; b; c; dÞvða− Þ ¼ 0
(4)
298 where
n is an element of X so that ∀a; b; c; ::: ∈ X : nðP∪I Þa; b; c; :::
a− is an element of X so that ∀a; b; c; ::: ∈ X : a; b; c; :::ðP∪I Þa−
δða; b; c; dÞ is the minimal number of categories of differnece of attractiveness
between the difference of attractiveness
between a and b and the difference of attractiveness between c and d:

In practice, the MACBETH methodology is based on a direct question–answer procedure.

Canas et al. (2015, p. 372) describe this as “the panelists compare pairs of alternatives and
project qualitative judgments about the difference in attractiveness between these
alternatives”. As such, several arrays of value judgments are defined until a range of local
preference for each descriptor included in the process is obtained.
Although the MCDA literature recognizes that there is no such thing as an overall superior
method or technique (e.g. Weber and Borcherding, 1993; Ananda and Herath, 2009; Zhou and
Ang, 2009), three major factors impacted on the decision on which methods to use in our
study, namely: (1) cognitive mapping and MACBETH are two well-established methods,
recognized for being simple and facilitating decision making across several organizational
contexts; (2) the authors of this paper have previous experience in their practical application,
and familiarity with the methods is an important factor to ensure their proper
implementation; and (3) we have found no prior documented evidence reporting the
integrated use of cognitive mapping and MACBETH to evaluate service quality in the
prosthodontics sector, allowing our proposal to contribute to the extant literature on service
quality evaluation and OR/MS.

4. Application and results

As mentioned previously, the present study’s main objective was the creation of a multiple-
criteria assessment system to evaluate service quality in the dental prosthetics sector.
According to the literature (cf. Belton and Stewart, 2002; Ferreira, 2011; Canas et al., 2015), the
MCDA approach requires a decision group composed of 5–12 individuals. In the current
research, the panel consisted of seven decision makers, who presented different social and
educational backgrounds but had in common that they were connected to the dental
prosthetics area as either specialized professionals (e.g. dental technicians and dentists) or
users of dental prostheses (i.e. patients), allowing for the enrichment of the discussion on
prosthodontics service quality evaluation. The panel members operated in the Central-West
region of Portugal, and their ages ranged between 32 and 52 years old.
Although a deeper characterization of the panel could have been developed, the
application of the selected methods sought neither to achieve representativeness nor to form
generalizations. Instead, this study focused strongly on the decision making process, with the
goal of bringing together the knowledge and experience of a group of relevant experts to
create new insights and include these in the proposed AI evaluation framework. This means
the results are somewhat idiosyncratic, but the procedures followed, when correctly adjusted,
can work well with different panels or in varied contexts (see Belton and Stewart, 2002; Bell
and Morse, 2013; Ormerod, 2013).
 The group sessions were coordinated by two facilitators (i.e. two of the authors of this study), Service
who also recorded the results obtained. In total, the three work sessions lasted 12 h (i.e. 4 h each). quality in
prosthodontics
4.1 Cognitive map development sector
The process of problem structuring consisted of identifying the criteria considered by the panel of
decision makers to be the most important aspects of quality of service in the dental prosthetics
sector. The first session began with a briefing to clarify the study’s methodology and purpose, 299
after which the following trigger question was asked: “Based on your values and experiences,
what characteristics should be associated with the best service in the dental prosthesis industry?”
This question facilitated the application of the “post-its technique” (Ackermann and Eden,
2001), which is the operational basis of the SODA approach. This technique follows two
simple rules. First, a post-it note is used to display each assessment criterion. Second,
whenever a negative cause-and-effect exists between two criteria, a negative sign () is added
in the upper right-hand corner of the respective post-it note (cf. Ferreira et al., 2016b; Ribeiro
et al., 2017; Azevedo and Ferreira, 2019).
As the group discussion evolved, the decision makers shared their values and knowledge
by placing post-it notes on a whiteboard. The next step involved the organization of the post-
it notes into clusters. This organization process allowed panel members to add new criteria to
the discussion or even eliminate repeated ideas. Finally, a means-ends analysis was
conducted within each cluster in order to identify the cause-and-effect relationships between
the criteria (for details, see Ferreira et al., 2017).
After the “post-its technique” stage, a cognitive group map was created using the Decision
Explorer software (https://banxia.com). Figure 2 shows the final version of the cognitive map,
which was validated by the decision makers through further analysis and discussion. As size
restrictions prevent the presentation of a clearer version of the map in this paper, an editable
version can be obtained from the corresponding author upon request.
The next step of the structuring process was an analysis of the lines in the cognitive map
in order to identify the possible criteria for FPsV. Following Keeney’s (1992) methodological
guidelines, common areas of relevance were found, based on which the FPsV could be
selected. These included “clinics and laboratories”, “dentist profiles”, “dental technician
profiles”, “patient profiles”, and “materials, equipment, and technology” (see Figure 3).
As Figure 3 shows, the proposed evaluation model was a result of the agreements reached
by the decision-maker group. The FPsV cover the following aspects:
(1) FPV01 (i.e. clinics and laboratories) includes the tangible and intangible
characteristics of these two spaces in terms of service provision;
(2) FPV02 (i.e. dentist profiles) covers the interpersonal and technical skills of dentists
that influence the services provided to patients in clinics;
(3) FPV03 (i.e. dental technician profiles) involves features of dental technician profiles –
predominantly the technical production of prostheses in specific physical contexts
(i.e. laboratories);
(4) FPV04 (i.e. patient profiles) comprises a set of exclusive patient conditions at the
interpersonal level, as well as patients’ state of health and expectations that influence
the performance of services provided by dental healthcare teams (i.e. dentists and
dental prosthesis technicians);
(5) FPV05 (i.e. materials, equipment and technology) includes tangible criteria related to
equipment and technology that can influence the quality of dental prosthetics
services.
 31,2

300
JOSM

Figure 2.
Group cognitive map
1 Service Quality of
Prosthdontics Sector

3 Aesthetics
2 Prosthodontics
Quality

76 Fayment Facility 9 Laboratory and

8 Materials,
Clinic
Equipment and 101 Equipments
86 Logistics -
Technology
77 Quality of 100 Assistance
Facilities Service
84 Marketing
78 Location 97 Accuracy
98 Materials 96 Warranty of
85 Human Resources 102 Suppliers Services, Equipment
79 Profit Margins Compliance with and Materials
99 Technology 90 Predictability of
82 Presence of 83 Quality/Price Delivery Deadlines
Final Results
80 Practiced Prices Technician at Clinic Ratio 4 Function

81 Light 87 Execution Time 88 Quality of

15 Regulation 91 Digital Design
Materials and
71 Communication Equipment 94 Limitations of
10 Sensibility 89 Photography and
Brriers Materials and
- 93 Investiment Video
5 Dentist Profile - Equipment 95 Use of Intraoral 152 Indecision
18 Experience
72 Interpersonal 92 CAD-CAM Scanner
151 Dental Anatomy
13 Professionalism -
Relationship -
-
- - -

139 Sincerity 7 Patient Profile -

31 Warranty -
150 Musuculoskeletal
70 Mood Disorders
24 Sympathy -
--
- -
- - --
- - - - --

37 Punctuality and
147 Limitations
Attendance 158 Personality
146 Pre-existing
22 Choice of Patient Conditions
Material 73 Exigency Level 138 Insurance
and Limitations

16 Honesty 46 Customization
149 Parafunction
Srategy to Increase
29 Appreciation of the Profit Margin
Details 148 Social Influence

36 Choice of Dental 55 Hands-On Courses

Technician/ 19 Academic Training 74 Exigency Level 145 Payment Terms
Laboratory

41 The Appearence of 48 Colour Importance 144 Systemic

75 Natural Prothesis
Teeth Diseases
14 Experience with 38 Contact between
Impression Technique the Patient and the 114 High Patient
Technician - Expectations 143 Previous
-
Treatments
30 Availability and 27 Feedback
Support Pre and Post 12 Technical 6 Dental Technician
20 Quality of Molds Treatment Profile 142 Check-ups
Competence
and Bites -

50 Professional -
- 141 Patient
Reputation - - -
42 Follow-Up and Punctuality and
Documentation 119 Treatment
33 Repetições Moldes 11 Communication Longevity Attendance
Expectations
- 43 Use of Original 56 Discussion and
- 140 Cancellations
and Certified Marks Work Plan Agreement
25 Anxiety
115 Clear and 137 Management
44 Medical Letter Clarifying Agendas
28 knowing Patient´s Information
Purposes
45 Persistence and 136 Finantial
40 Showing Patience Availability
Confidence
26 Empathy
68 Inappropriate 135 Cooperation
Schedules to a 120 Insecurity
Healthy Eating 134 Perceived
108 Logistics Costs Quality
66 Speed of
65 Music Execution 116 Lack of 132 Personal Taste
Confidence in the
67 The Ability to Doctor
Anticipate Problems 133 Respect
107 Ability to
69 Quality of 54 Artistic Assume Technical 131 Pain
Provisional Failure 121 Anxiety
Sensitivity 157 Discomfort of
Prosthesis Responsibility
17 Information not being able to
62 Technical speak during
Knowledge of Used treatment
117 Tooth Shape
Materials
60 Pressure due to
21 Ability to Inform the Amount of Work 155 Ability to be
about the 106 Ability to 122 Priority
Management Grateful
Possibility of Reproduce Dental
Future Problems Anatomy
51 Motivation 130 Trust in the
47 Inform about Doctor
105 Low Profit
Patient´s Rights in Margins 118 Guarantee of
61 Budget Quality
case of 129 Fear of breaking
Dissatisfaction with the Prothesis or
the Performance 57 Reproduction of that it doesn´t Fit
104 Delivery
Tooth Shape
Deadlines
39 Materials Used in 125 Observing your 154 Vomiting Reflex
58 Working Protocols Dentist Academic
Rehabilitation
34 Quality of Training Diplomas
Information that is and Specialization
Sent to the Courses 156 Mouth-Opening
32 Clarity and Ability
Transparency of Laboratory 103 Price 109 Technical
Medical Acts to 49 Warranty Availability to See
Perform 64 Execution Time the Patient 127 Very High Price
Required 124 Negative
52 Professionalism
63 Rigorous Feedback of other
-
-
Validation of Patients 153 Kind of Smile
53 Learning Curve of
Impressions
Materials Used 111 Ensure Patient´s 159 Gender
Safety 128 Availability for
123 Knowledge of Change
59 Bad Technical Prothesis Cost and
Performance of 110 Fees 112 Professional Clinical Treatment
Prothesis Qualification to be 126 Lack of Empathy
with the Patient
113 Communication
Barrier
During the structuring phase, a descriptor and respective impact levels were also defined for Service
each FPV. The elaboration of descriptors and levels of impact required a meticulous analysis quality in
of the cognitive map generated, which took place during the second group work session. The
most important criteria in the evaluation of service quality in the dental prosthetics sector
prosthodontics
were identified for each cluster, and using an adapted form of Fiedler’s (1967) scale, partial sector
and reference performance levels were defined for each descriptor. Thus, the level of impact
L1 represents an excellent partial performance, while Ln expresses the worst possible
performance. To provide an example, Figure 4 presents the descriptor created for FPV03. 301
The descriptor of FPV03 (i.e. dental technician profiles) in Figure 4 includes some features
related to dental technicians. At the positive extreme of the descriptor lies an extremely
professional profile, absolute technical competence, excellent knowledge of the materials
used, an excellent ability to reproduce dental anatomy, a highly developed aesthetic
perception, strict compliance with delivery dates and total availability to follow patients’
progress. At the negative extreme are the opposite constructs, as per Fiedler’s (1967) scale. In
addition, L1 corresponds to an excellent local performance and expresses the best score
possible, whereas L5 and L6 represent negative evaluations of the services provided.

4.2 Evaluation phase

To continue the decision support process, the evaluation phase comprised the use of the
MACBETH methodology to fill out a value judgment matrix and construct preference scales,
which facilitated the operationalization of the descriptors previously created. This phase
coincided with the third group session.
At this stage of the process, cardinal scales could be developed based on semantic
categories of value judgments (cf. Ferreira, 2011). Thus, using the semantic categories of
difference of attractiveness presented in Table 3, a value judgment matrix could be filled in,
thereby generating a performance scale for each FPV. For instance, FPV03 (i.e. dental
technician profiles) was operationalized with six reference levels (see Plate 1). After using the
M-MACBETH software (http://m-macbeth.com/), these levels reflected a value function that
assigned 140 points to the best level (L1) and 120 points to the worst level (L6). The decision

Service Quality in the Prosthodontics Sector

Clinics and Laboratories
Dentist Profiles
Dental Technician Profiles
Patient Profiles Figure 3.
Tree of FPsV
Materials, Equipment and Technology

Descriptor FPV03 - Dental Technician Profile [DTP] Level Description

L1 ∈

Good ∈

L3 ∈

Neutral ∈

L5 ∈ Figure 4.
L6 ∈
Descriptor and levels of
impact for FPV03
JOSM
31,2

302

Plate 1.
Value judgments and
proposed scales
for FPV03

makers identified L2 as the “Good” level, with a score of 100 points, while L4 was rated with a
score of 0 points since it was considered the “Neutral” level.
After obtaining a performance scale for each of the five FPsV of the proposed model, the
next phase consisted of calculating the trade-offs (i.e. weights or substitution rates) among
the FPsV. The decision makers were asked to focus their attention on the FPsV and put them
in order by their degree of global relevance. This exercise was carried out using fictitious
alternatives to compare the attractiveness of the “swings” of the FPsV, avoiding the “most
common critical mistake” in decision analysis (Keeney, 1992). Thus, a matrix could be filled in
as the panel of decision makers assigned the value of 1 whenever an FPV was considered
more significant than another FPV – and zero otherwise. The result of the ordination process
is shown in Table 4, in which column R lists the ranking obtained.
After the FPsV were ranked, a value judgment matrix was filled in to obtain the model’s
trade-offs. The decision makers were asked to project their value judgments regarding the
difference of attractiveness between FPsV. Plate 2 presents the resulting value judgment
matrix and normalized weights for the FPsV.
As can be seen in Plate 2, the most significant FPV is FPV03 (i.e. dental technician profiles)
with 35.71%, followed by FPV02 (i.e. dentist profiles) and then FPV01 (i.e. clinics and
laboratories) with 28.57 and 21.43%, respectively. FPV04 (i.e. patient profiles), with 3.57%, is
considered the least important FPV for quality of service in the dental prosthetics sector,
based on the value judgments of this study’s expert panel.

FPV01 FPV02 FPV03 FPV04 FPV05 Total R

Clinics and laboratories FPV01 0 0 1 1 2 3

Dentist profiles FPV02 1 0 1 1 3 2
Dentist technical profiles FPV03 1 1 1 1 4 1
Table 4. Patient profiles FPV04 0 0 0 0 0 5
Matrix of overall Materials, equipment and FPV05 0 0 0 1 1 4
preferences technology
 Although intriguing, the results obtained need to be interpreted with caution since they Service
are based on decision makers’ value judgments. Additional analyses were conducted in order quality in
to reinforce the empirical validity of these results. Therefore, the decision makers were asked
to provide specific information concerning actual clinics they know (hereafter termed
prosthodontics
“Deltas”), where dental prosthetics services are provided. Although this information could sector
not be considered statistically representative, it was necessary to test the practical
application of the proposed evaluation system. After the partial evaluation process was
completed, the next phase was the aggregation of partial evaluations of the Deltas using a 303
simple additive model (see Ferreira et al. (2012)). Plate 3 shows the partial and global
attractiveness values revealed by the Deltas.
The aforementioned ranking of the Deltas was exploratory in nature since the analysis
only included nine Deltas. However, the results contribute to some important conclusions.
Given that dental prosthetics is a healthcare service, the performance values of the evaluated
Deltas can feasibly exceed the “Good” reference level (i.e. 100 points). Consequently, the top
values given to the Deltas’ performance are quite high, reflecting not only excellent patient
care but also mostly private services. Finally, comparing the Deltas with the Good and

Plate 2.
Value judgment matrix
of FPsV

Plate 3.
Partial and overall
attractiveness scores
JOSM Neutral reference performance levels facilitates a clearer understanding of the relative
31,2 position of these facilities’ quality of services.
Despite the satisfaction expressed by the decision makers regarding the Deltas’ ranking,
the most important result is the proposed system’s demonstrated ability to evaluate the
Deltas’ profiles and thereby identify the cases in which improvements are needed. For
instance, Plate 4 presents the impact profiles of Delta 02 and Delta 08, which provide useful
information about the possible causes of low performance levels.
304 The analysis of the Deltas’ profiles was the final step in the evaluation phase, so the
conditions for different complementary analyses were established. These were needed not
only to reinforce the validity of the results obtained but also to evaluate the consistency and
stability of the proposed evaluation model.
According to Bana e Costa and Chagas (2004), sensitivity analysis can be used to verify how
a change in the weight of any of the FPsV influences the model’s overall results. Thus, several
analyses were performed to test the sensitivity of the proposed evaluation system of the
services provided in the dental prosthetics sector. Plate 5 shows, as an example, the sensitivity
analysis performed for FPV01 (i.e. clinics and laboratories), whose defined weight was 21.43%.
According to Plate 5, based on FPV01’s weight interval oscillation, the Deltas’ evaluation
results can be considered quite robust. Any oscillation in the weight of FPV01 – within the
defined interval – will have no influence on the Deltas’ ranking or on the decision makers’
judgments. The same analysis was conducted for all the FPsV included in the model.
However, because this analysis dealt with isolated variations of the FPsV’s weights, it was
complemented with robustness analyses.

Plate 4.
Impact profiles of Delta
02 and Delta 08
 Service
quality in
prosthodontics
sector

305

Plate 5.
Sensitivity analysis of
weight of FPV01 and
intervals for FPV
coefficients of variation

Plate 6 shows the results for one of the robustness analyses carried out. These show several
situations of additive dominance ( ), in which one Delta X could be globally rated as better
than another Delta Y due to the weighting coefficients, although this did not happen for all the
FPsV. Plate 6 also reveals some situations of classical dominance ( ), in which a Delta X is
always preferred over another Delta Y, independently of the weighting coefficients (for
technical details, see Oliveira et al., 2017).
As Plate 6 shows, for a margin of uncertainty of þ10% and þ8% in FPV02 and FPV03
scores, respectively, the conclusion can still be drawn that Delta 07 dominates Deltas 03, 05,
06 and 08 since, independently of the weighting coefficients, the overall value of Delta 07 is
always higher than the values of the other Deltas. In practical terms, these final analyses
could be particularly useful when attempting to reach conclusions in the context of imprecise,
scarce or uncertain information.

Plate 6.
Robustness analysis of
overall framework
JOSM 4.3 Consolidation and recommendations
31,2 To reinforce the validity of the present results and methodological processes, a final session
was held with the vice-president of the Associaç~ao Portuguesa de Tecnicos de Protese
Dentaria (APTPD) (i.e. Portuguese Association of Dental Prosthesis Technicians). This
consolidation session was important since the person interviewed was neutral about the
entire process (i.e. this individual did not participate in the panel meetings), as well as being a
representative professional in the sector and thus familiar with its practices.
306 This final session was used to solidify the results and confirm that the proposed
assessment procedures can be considered of significant value to the prosthodontics sector.
The session had the following objectives:
(1) To understand the dental prosthetics sector in terms of service quality evaluation and
the ways the integrated use of SODA and MACBETH could add value to the existing
evaluation mechanisms;
(2) To formulate conclusions about how the techniques used contribute to addressing the
decision problem under study;
(3) To elicit comments about the strengths and weaknesses of the proposed model, as
well as those of the methodologies applied;
(4) To reinforce the validity of the results of the group sessions.
The session began with a brief presentation of the research objective, namely to identify the
most current criteria for evaluating service quality in the dental prosthetics sector. The
interviewee’s response to this revealed that no well-defined evaluation indicators exist. He
then pointed out that, in an environment in which no evaluation systems exist, this type of
initiative is always positive. More specifically, the interviewee emphasized the academic
development of the sector, which has led to necessary present and future transformations.
Thus, this individual understood the need for a more comprehensive evaluation system
capable of assessing different variables.
Regarding the ranking of FPsV, the interviewee agreed overall with the impact of FPV03 (i.e.
dental technician profiles) on quality of service in the dental prosthesis sector compared to the
other FPsV. This confirmation underlines the importance and value of dental technicians in oral
health teams. The final phase of the session consisted of eliciting answers to formulate
conclusions and prepare recommendations. The responses contributed to the conclusion that,
despite being a process strongly dependent on the decision makers’ values – as the interviewee
put it – “the system developed allows for the identification of gaps in order to improve the
quality of service in the dental prosthesis sector”. The interviewee also emphasized that he was
“impressed” with the processes followed.
Regarding recommendations, one goal of this study was to develop a multiple-criteria
model to support decisions about quality of service in the sector under study. However, the
findings are clearly idiosyncratic, and they do not focus on absolute or definitive solutions
(cf. Bell and Morde, 2013; Spyridakos and Yannacopoulos, 2014). Thus, the most significant
contribution of the present study was to provide a complete and well-informed quality of
service evaluation in the dental prosthetics sector, providing plentiful, useful information
through the methodologies applied.

5. Conclusion
No evidence was found in the literature reporting the integrated combination of cognitive
mapping and the MACBETH approach to evaluate quality of service in the dental prosthetics
sector, supporting the innovative nature of our study.
 The application of the methodological processes described earlier facilitated the Service
development of an empirically robust AI evaluation model in this study context. This quality in
main objective was achieved through an exchange of information, experiences and values
with a group of experts in this sector, who participated in three group sessions for the
prosthodontics
development of the proposed evaluation model. Thus, the constructivist nature of the sector
learning process that was the basis for the development of the model allowed these experts to
express their points of view with greater transparency. This learning process contributed to
the collection of data essential to the validity of the system created, including completing it 307
and testing its robustness, reliability and practical applicability.
After verifying the relative weight of each of the FPsV in the evaluation of quality of
service in the dental prosthetics sector, the results confirmed that both dental technician
profiles and dentist profiles have a slightly higher weight in relation to the other FPsV.
Notably, this study did not seek to find optimal solutions but instead to apply methodologies
that – as they are based on discussions among experts – facilitate a better understanding of
service quality evaluation in the prosthodontics sector. From this perspective, the
complementary stance of our study should be highlighted, making clear that the aim was
not one of substitution of previous methods or models, but rather their augmentation. Indeed,
by allowing prosthodontics clinics to be analyzed and evaluated in a structured and
meaningful way, our proposal assumes a complementary – rather than comparative –
perspective. As a result, the use of the methodological combination proposed in this study
allowed for the construction of a different, but complementary model to those already
existing and resulted in the design of a transparent, complete and well-informed system,
comprising both objective and subjective components.
Following this, the contributions are both methodological and with regard to the findings.
Although our results are idiosyncratic, they can be an important starting point for other
researchers and practitioners hoping to evaluate quality of service in the prosthodontics
sector. Methodologically, the contribution is twofold: it comes both from the combined use of
cognitive mapping and MACBETH, which we believe to be novel in this study context and
from the description of the process followed, which can allow for replications with different
expert panels and/or in other sectors (cf. Bell and Morse, 2013; Ormerod, 2013; Ferreira
et al., 2017).
Based on the insights obtained from a real-life application of our framework in the
prosthodontics sector, one may conclude that cognitive mapping can be generally used in the
fields of service quality evaluation and AI to reduce the number of omitted criteria in decision
support processes, as well as to gain a fuller understanding of the cause-and-effect
relationships between concepts and/or decision criteria. As pointed out by Eden and
Ackermann (2004), cognitive maps help reduce cognitive load, enhancing the recall and
acquisition of information regarding decision criteria and their respective cause-and-effect
relationships. MACBETH, in turn, can be used for calculating criteria trade-offs, fostering
informed/conscious decision making based on expert knowledge (Ferreira and Santos, 2019).
In light of this reasoning, and because the combined use of these methodologies fosters a
deeper understanding of decision situations, providing answers to questions such as “why
does this happen?”, its benefits include the handling of ill-structured information, the
construction of advanced decision models and the development of efficient computational
algorithms for problem solving and machine learning. Indeed, by modeling diagrams and
representing cause-and-effect relationships between decision criteria, better informed and
more grounded decisions can be made based on a fuller understanding of the dynamics
involved in service management. In addition, the integration of these decision-support
techniques into practices can greatly enhance the accurate structuring of complex decision
problems, thereby supporting decision making. This seems to be very useful in service
management- and AI-related fields, because it can support attempts to extract and codify
JOSM human expertise in computer programs. It also allows rules for decision making to be
31,2 provided, which can be included in systems with implementation delays and resource
constraints. Finally, from a constructivist perspective, this also means that the evaluation
system created to measure service quality should be seen as a learning mechanism and not as
an end in itself or a tool to prescribe optimal solutions. As discussed earlier, with the
necessary adjustments, the processes followed in the present study can work well with a
different group of participants or in any other service context (cf. Bell and Morse, 2013;
308 Ormerod, 2018). This is a reflection of the constructivist nature of the framework proposed in
the present work.
Given the idiosyncratic nature of the proposed evaluation model, future studies could
apply other AI-MCDA techniques (see Belton and Stewart, 2002; Zavadskas et al., 2014) and
compare the results. Although not an objective of the present paper, namely because of the
scarcity of evaluation instruments in the prosthodontics sector, we recognize the importance
of methodological comparisons and believe it to be a worthwhile research avenue. In addition,
further advantages may be gained by extending the data collection through the participation
of other experts from different geographical areas or those with different academic training.
Any advances made will be well received by the professionals of the services sector.

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About the authors

Sara M. Martins is an entrepreneur working in the prosthodontics sector. She owns a clinic and a
laboratory. Her research interests include service quality in the dental prosthetics sector and decision
support systems (DSS).
Fernando A.F. Ferreira is Associate Professor (w/Habilitation) and former Vice-Dean (2014–19) for
financial affairs at the ISCTE Business School of the University Institute of Lisbon, Portugal. He is also
Adjunct Research Professor at the Fogelman College of Business and Economics of the University of
Memphis, TN, USA. He holds a PhD in Quantitative Methods Applied to Economics and Management
from the University of Algarve, Portugal. Some of his articles are published by ISI-listed journals such as
Annals of Operations Research, Journal of the Operational Research Society, Journal of Business
Research, Technological Forecasting and Social Change, Management Decision, Service Business and
International Journal of Information Technology and Decision Making. He has practical experience as
group facilitator, and his research interests include multiple-criteria decision analysis, fuzzy logics and
integrated systems for performance measurement.
Jo~ao J. M. Ferreira is Associate Professor at the University of Beira Interior (UBI), Portugal. He holds a
PhD in Entrepreneurship and Small Business Management from the Autonomous University of
Barcelona (UAB), Spain. Currently, he is the scientific coordinator of the UBI Research Unit for Business
Sciences (NECE), Portugal. He has published over 200 papers in premier international journals and
edited or coedited several books on innovation and entrepreneurship. His research interests include
strategy, competitiveness and entrepreneurship. Jo~ao Ferreira is the corresponding author and can be
contacted at: jjmf@ubi.pt
Carla S.E. Marques is Assistant Professor (w/Habilitation) at the Department of Economics,
Sociology and Management, University of Tras-os-Montes e Alto Douro (UTAD), Vila Real, Portugal.
Currently, she coordinates the “Innovation, Markets and Organization” research group at UTAD Centre
for Transdisciplinary Development Studies (CETRAD). Her research on innovation and
entrepreneurship has been presented at numerous international conferences and published in premier
international journals such as Service Business, Journal of Business Research, International Journal of
Management and Enterprise Development, International Entrepreneurship and Management Journal
and Management Research. Her research interests include innovation, management of change and
entrepreneurship.

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