International Dental Journal 2019; 69: 252–264

CONCISE REVIEW
doi: 10.1111/idj.12453

A systematic review of quality measures used in primary

care dentistry
Matthew J. Byrne1 , Martin Tickle1, Anne-Marie Glenny1, Stephen Campbell2,
Tom Goodwin1 and Lucy O’Malley1
1
Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK;
2
NIHR Patient Safety Translational Research Centre, Division of Population Health, HSR & Primary Care, School of Health Sciences, Faculty
of Biology, Medicine and Health, University of Manchester, Manchester, UK.

Introduction: ‘Quality’ in primary care dentistry is poorly defined. There are significant international efforts focussed on
developing quality measures within dentistry. The aim of this research was to identify measures used to assess quality in
primary care dentistry and categorise them according to which dimensions of quality they attempt to measure. Methods:
Quality measures were identified from the peer-reviewed and grey literature. Peer-reviewed papers describing the devel-
opment and validation of measures were identified using a structured literature search. Measures from the grey literature
were identified using structured searches and direct contact with dental providers and institutions. Quality measures were
categorised according to domains of structure, process and outcome and by disaggregated dimensions of quality. Results:
From 22 studies, 11 validated measure sets (comprising nine patient satisfaction surveys and two practice assessment
instruments) were identified from the peer-reviewed literature. From the grey literature, 24 measure sets, comprising 357
individual measures, were identified. Of these, 96 addressed structure, 174 addressed process and 87 addressed outcome.
Only three of these 24 measure sets demonstrated evidence of validity testing. The identified measures failed to address
dimensions of quality, such as efficiency and equity. Conclusions: There has been a proliferation in the development of
dental quality measures in recent years. However, this development has not been guided by a clear understanding of the
meaning of quality. Few existing measures have undergone rigorous validity or reliability testing. A consensus is needed
to establish a definition of quality in dentistry. Identification of the important dimension of quality in dentistry will allow
for the production of a core quality measurement set.

Key words: Quality, measurement, improvement, indicators

process involving dental professionals, patients and

INTRODUCTION
Improving quality in primary dental care is a goal of
international interest1,2. To improve the quality of
health care, a definition of quality and the criteria
used to assess quality must be established3. Most defi-
nitions of quality in primary care relate to medicine.
Within medicine, several different definitions have
been described4–13. Dentistry has a number of signifi-
cant differences from medicine, which has led to sug-
gestion of the need for a specific definition of quality
in dentistry to be developed3. Whilst some specific
definitions for quality in dentistry have been
offered14,15, there is no agreed definition or concep-
tual framework available describing what quality
means for primary dental care1,3,16. The World Dental
Federation (FDI) has defined quality as ‘an iterative
252
other stakeholders to develop and maintain goals and
measures to achieve optimal health outcomes’2. This
statement highlights the importance of measurement
of quality in the process of improving patient care.
However, the constituent parts of this and other defi-
nitions need to be considered further to ensure that all
of the key dimensions of quality are captured. Fur-
thermore, the view that dentistry is so different from
other areas of health care that it merits its own defini-
tion must be tested.
Many quality assurance and improvement schemes
have been attempted but are hampered by a weak evi-
dence base17. The Institute of Medicine (IoM) in the
USA has stated that quality measures in dentistry ‘lag
far behind’ those in medicine and other health profes-
sions18. The IoM suggests that construction of quality
© 2018 FDI World Dental Federation

measures would help to improve oral health and
reduce inequalities18. A first step in this process would
be to develop a comprehensive understanding of what
type of measures have been developed and what
dimensions of quality they are attempting to measure.
Quality is complex and multi-dimensional; therefore,
a structured approach to terminology usage is neces-
sary to avoid confusion. We propose the following
terminology for categorising quality measures:
Domains
The Donabedian system-based model of quality states
that quality measures may address one or more of
three domains, namely: the structures that contribute
to the delivery of care; the processes of care; and the
outcomes of care6. Measures of structure include
assessments of the provision of facilities, staff and
training. Process measures assess what the practitioner
actually does, and outcomes measurements assess the
impact of an intervention6. Evidence is required to
show that the measurement and improvement of pro-
cesses will lead to an improvement in outcomes19, for
example, if placement of fissure sealants (process)
leads to prevention of caries (outcome).
Dimensions
Quality may be disaggregated into different dimen-
sions. These dimensions each give a partial view of
quality7. The IoM definition of quality identifies
dimensions of safety, effectiveness, timeliness, patient-
centredness, efficiency and equity13. There is no con-
sensus on the dimensions of quality that are most per-
tinent to dentistry.
An ideal measure set in dentistry would address
each of the dimensions of quality across the domains
of structure, process and outcome.
The aim of this research was to identify measures
used to assess quality in primary care dentistry.
Measures were categorised according to the IoM’s
dimensions of quality and the Donabedian domains of
the IoM. The identification of these measures will
assist in the production of a framework to support
further development of quality measures in dentistry.
METHODS
Peer-reviewed literature
A systematic search strategy was used to identify mea-
sures from the published literature (Appendix 1). Each
identified measure was assessed for internal and exter-
nal validity. The constituent parts of each measure
were assessed for the Donabedian domain and IoM
disaggregated dimension of quality that they measure.
© 2018 FDI World Dental Federation
Systematic review of quality measures
Inclusion criteria
Types of study
Any cross-sectional or longitudinal study concerning
the development or validation of a quality measure in
primary care dentistry or that uses a previously
reported measure.
Types of measure
The types of measure included were those that may
be used by a dentist, patient or other stakeholder to
assess quality in a primary care setting.
Studies were only selected if they presented the pro-
cess by which the measure was developed and vali-
dated in sufficient detail. Measures that had their
validity confirmed in later studies were also included.
Exclusion criteria
Non-peer-reviewed studies or opinion pieces, studies
published in a language other than English, studies
published pre-1970 and studies that did not describe
development or validity testing of the measure were
excluded.
Measures of oral health-related quality of life
(OHRQoL), being primarily epidemiological tools,
were excluded.
A structured systematic literature search was pro-
duced for use in MEDLINE (Appendix 1) and
adjusted for other databases. The Databases used
were MEDLINE via OVID (1946 to present), Psych-
info via OVID (1806 to present), EMBASE via OVID
(1980 to present), Health and Psychosocial Instru-
ments via OVID (1985 to present) and Social Policy
and Practice via OVID.
The screening process was managed using an End-
note Library; references were initially screened accord-
ing to title and abstract by MB, AG, MT, SC and LO,
and irrelevant papers were removed. The remaining
papers were double screened by MB and AG, with
disagreements discussed with MT. Full-text papers
were obtained for the remaining included studies. Ref-
erence lists of these studies were hand searched to
obtain key sources that described the development or
validation of the measures. Key journals were directly
searched to identify articles that may have been miss-
ing from the literature search strategy.
Grey literature
Searching of the grey literature was completed using
the OpenGrey database20 and through hand searching
of the websites of large dental providers, dental asso-
ciations, insurers and government bodies in English-
253
Byrne et al.
speaking nations (the USA, Canada, the UK, Australia
and New Zealand). Dental insurers and large corpo-
rate dental providers were contacted directly and
asked to state any quality measures they use. The
National Quality Forum’s ‘Environmental Scan, Gap
Analysis & Measure Topics Prioritization’ was con-
sulted, as this project had similar goals of measure
identification as the present study17. A number of the
measures identified within this study are no longer in
use and were thus omitted. As measures from the grey
literature are actively measuring and affecting clinical
practice, exclusion criteria were limited to non-English
references and publication before 1970.
Evaluation and categorisation of measures
As there is no established measure to assess the qual-
ity of quality measures within primary care dentistry,
the measures were individually assessed to determine
their internal and external validity. Measures that did
not demonstrate face validity were excluded. Evalua-
tion of the internal consistency of measures, such as
Cronbach’s alpha scores, was extracted. An a < 0.5
suggests unacceptable internal consistency of the mea-
sure21. Measures of test–retest reliability, such as intr-
aclass correlation coefficients and Spearman’s rank
correlation coefficients, were also extracted. Each
measure was categorised according to the Donabedian
domains of Structure, Process and Outcome and then
assessed against the six disaggregated dimensions of
quality of the IoM definition of quality.
Method of analysis and synthesis
Structured tables were used to describe the data from
each measure narratively to give an overview of the
domains of quality evaluated using each measure and
the dimensions of quality they address.
RESULTS
Measures from the peer-reviewed literature
A flow diagram of the screening process is presented
in Figure 1. A total of 543 papers were generated
from the structured literature search. Seven additional
papers were identified following further searches.
Removal of 49 duplicates gave 501 papers for initial
analysis. Of these, 285 were excluded as they were
irrelevant. The full text of the remaining 216 papers
was assessed. Following this, 22 papers met the inclu-
sion criteria. Within these papers, 11 individual mea-
sure sets were identified: nine were patient satisfaction
scales and two were practice assessment instruments
for use by a dentist or practice manager.
254
Number of records Number of additional records
identified through identified though other
database searching: sources:
n = 543 n=7
Number of records after duplicates removed
n = 501
Number of records screened Number of records excluded:
n = 501 n = 285
Number of full-text papers Number of full-text papers
assessed for eligibility: excluded
n = 216 n = 194
Number of Records included in qualitative synthesis
n = 22
Figure 1. PRISMA flow diagram of literature screening and identifica-
tion process.
Table 1 summarises the contents of each measure
and describes the internal validity and reliability test-
ing of the included measures. Further studies that
make use of the measure are described. Satisfaction
was assessed in the nine patient satisfaction scales
using Likert-style scores. These measures were to be
completed by the patient receiving treatment or by
their parent/guardian. Similar ordinal rating scales
were used by the measures described in the two prac-
tice assessment tools. These measures were designed
to be completed by a dentist or manager in the dental
practice.
All the included measure sets showed face validity.
Cronbach’s alpha was used to describe internal valid-
ity in all of the measures. All were above the accept-
able level of a = 0.721, except the Dental
Management Survey Brazil (DMS-BR)22, with
a = 0.632 (suggesting questionable internal consis-
tency), and components of the Dental Satisfaction
Questionnaire (DSQ)38. The validity of the DSQ is
demonstrated by Chapko44; the measurement concept
of ‘Cost’ was suggested as unreliable (a = 0.47). All
other measures in this set had a > 0.6. Test–retest
reliability was reported in five of the measures, using
either intraclass correlation coefficients or Spearman
rank correlation coefficients, all of which showed
acceptable values.
The patient satisfaction scales broadly considered
patient satisfaction with the care received. For these
measures, satisfaction can be considered as an out-
come of care. Where specific questions address the
procedural aspects of care, the domain of process is
also measured. The Burdens in Prosthetic Dentistry
Questionnaire (BiPD-Q) 27 and Burdens in Oral Sur-
gery Questionnaire (BiOS-Q)29 measures were specifi-
cally related to satisfaction with processes of care and
© 2018 FDI World Dental Federation
 Table 1 Contents of each measure set identified in the peer-reviewed literature outcomes of internal validity and reliability testing of the measure sets
identified in the peer-reviewed literature
Measure set name Key Further Description of measure contents Items Type of Internal Test–retest Domain IoM
and abbreviation reference references using (n) measure consistency reliability dimensions of
measure (Cronbach’s quality
alpha a) assessed

Dental Gonzales22 N/A Self-assessment tool for use by dentists 6 Practice a = 0.632 Intraclass Structure Safety,
Management and practice managers to assess the assessment correlation efficiency
Survey Brazil quality of safety and organisational tool

© 2018 FDI World Dental Federation

coefficients = 0.93
(Dimension 6) aspects of dental care delivery and 0.94
(DMS-BR)
Survey of Goetz23 N/A Self-assessment tool of structural 20 Practice a = 0.775 Intraclass Structure Safety,
Organisational elements of the delivery of dental care, assessment correlation patient-
Aspects of Dental with focus on teamwork, leadership tool coefficients = 0.732 centredness
Care (SOADC) and the implementation of change
within a practice
Dental patient Cheng Wong25 Patient satisfaction scale on the quality 16 Patient a = 0.94 Intraclass Outcome Patient-
feedback on et al.24 of information provided by the dentist satisfaction correlation centredness
consultation skills to patients in consultations and the survey coefficients = 0.89
(DPFCS) atmosphere of trust generated
Tool Developed Bahadori26 N/A Patient satisfaction scale of the 30 Patient a = 0.71–0.91 Not reported Structure, Effectiveness,
from Parasurman structures and processes of primary satisfaction process patient-
and Zalathml dental care. Focus on the settings in survey centredness,
Construct of which dental care is delivered and timeliness,
quality communication between dentists and efficiency
patients
Burdens in Reissman27 Hacker28 Patient satisfaction scale of the 25 Patient a = 0.87 Not reported Process Patient-
Prosthetic perceived burdens of the processes of satisfaction centredness
Dentistry dental treatment during prosthetic survey
Questionnaire dental procedures
(BiPD-Q)
Burdens in Oral Reissman29 N/A Patient satisfaction scale of the 16 Patient a = 0.84 Intraclass Process Patient-
Surgery perceived burdens of the processes of satisfaction correlation centredness
Questionnaire dental treatment during oral surgical survey coefficients = 0.90
(BiOS-Q) procedures
Tool after Kikwilu30 N/A Patient satisfaction scale of the 11 Patient a = 0.849 Spearman rank Outcome Effectiveness,
‘Consensus perceived quality of the setting of satisfaction correlation timeliness
workshop for delivery of dental care and perceptions survey coefficients = 0.751
selecting essential of treatment quality and –0.923
oral health communication
indicators in
Europe’
Tool developed Keller31 N/A Patient satisfaction scale of the 23 Patient a = 0.74 Not reported Outcome Timeliness,
from Consumer perceived quality of information, satisfaction effectiveness
assessment of communication and dental care survey
Healthcare received by dental plan holders
Providers and
systems

(continued)
Systematic review of quality measures

255
 Byrne et al.

dimensions of the procedural elements of prosthetic dentistry and

effectiveness
Effectiveness,

Effectiveness,

centredness,
centredness

centredness
assessed

Timeliness,
quality oral surgery. Structure was measured in the practice
IoM

patient-

patient-

patient-
self-assessment tools [DMS-BR22 and Survey of
Organisational Aspects of Dental Care (SOADC)23]
and concerned the training of staff and provision of

Outcome
Outcome
safety equipment and data management. The ques-
Domain

Outcome

Structure
tionnaire developed by Bahadori et al.26 asked
patients to rate the importance of a number of struc-
tures and processes within a dental clinic, including
the state of facilities and the communication skills
exhibited by the dentist.
Test–retest
reliability

The practice assessment measures (DMS-BR22,

Not reported

Not reported

Not reported

SOADC23) assessed the dimensions of (i) safety, with

measures addressing the use and provision of personal
protective equipment and (ii) efficacy, using measures
of ability of practice members to work as a team. The
Chapko) = 0.46

patient satisfaction surveys covered a range of dimen-

(Cronbach’s
consistency

a = 0.83 and
alpha a)
Internal

sions, for example: safety – satisfaction with cleanli-

a = (from

ness of facilities30; effectiveness – satisfaction with

a = 0.92

–0.78
0.84

treatment received33; patient-centredness – perception

of dentist caring about patient32; timeliness – satisfac-
tion with waiting times to see a dentist31; efficiency –
satisfaction

satisfaction

satisfaction
measure

patient satisfaction of cost38; and equity – patient per-

Type of

survey

survey

survey

ception of dentist acceptance of them as a person33.

Patient

Patient

Patient

Measures from the grey literature

Items
(n)

10

10

10

In total, 24 collections of quality measures sets were

identified, with a total of 357 individual quality mea-
communication, information given and

communication of oral health, rapport

Patient satisfaction scale, assessing ease

Patient satisfaction scale regarding the

sures contained therein. Table 2 describes the mea-

Description of measure contents

surement sets qualitatively in terms of what attributes

with dentist and comfort during

of access, communication and

they attempt to measure, evidence of validity testing

environment of care deliver

and categorisation of measures according to domain

Patient Satisfaction scale,

and IoM dimensions. The majority of measures within

thoroughness of care

these sets (n = 196/357) followed a numerator/denom-

inator format, wherein the patients receiving a treat-
ment process or reporting an outcome were classed as
treatment

the numerator and a target population was identified

as the denominator. These types of quality measure
are presented as a percentage. A further 36 measures
were patient satisfaction measures using Likert-style
Mascarenhas43
references using

ordinal rating scores. The Denplan Excel Quality

Stouthard37
Hakeberg36
measure

measures68 contain 122 checklist-style ‘yes/no’

Milgrom40
Further

Brennan42
Olausson34

Chapko44
Skaret41

responses. The only measures that described validity

Sun35

Lee39

or test–retest reliability were those developed by the

Dental Quality Alliance49–51. These measures have
been developed according to the National Quality
Davies and
Corah and
Larrsson32

O’Shea33
reference

Forum measure development guidance69.

Ware38
Key

Approximately half (48.7%, 174/357) of measures

Table 1 continued

assessed processes of care provision. Common themes

for process measures were the provision of fluoride,
Dental Satisfaction
Satisfaction Scale
Measure set name

Quality from the

and abbreviation

fissure sealants and annual reviews. There was a high

Questionnaire

Questionnaire

degree of repetition of these concepts across a number

Perspective

Dental Visit
Patient’s

of measure sets. A total of 24.4% (87/357) measured

(DVSS)

(DSQ)

outcomes, with patient satisfaction ratings making up

52.9% (46/87) of these outcome measures. The
256 © 2018 FDI World Dental Federation
 Systematic review of quality measures

Table 2 Qualitative description of measure sets identified from the grey literature summarising evidence of valida-
tion, and categorisation of measure sets according to domains and dimensions of quality
Measurement collection Items Description of measure Domains Dimensions Validation
(n)

Dental Quality and Outcomes 15 Measures of patient satisfaction of Process, Safety Not reported
Framework45 their dental state and dental Outcomes Effectiveness
practice, clinical effectiveness and Patient-
patient safety centredness
Timeliness
NICE oral health in care 9 Measure of the oral health needs Structure, Patient- Not reported
home46 of nursing and care home Process, centredness
residents and the provision of Outcome Effectiveness
care Equity
NICE oral health promotion in 15 Measures of access to health- Structure, Patient- Not reported
the community47 promotion resources within the Process, centredness
community Outcome Effectiveness
Equity
Dental Assurance Framework 12 Claim data-based assessment of Process, Effectiveness Not reported
Policy48 provision of fluoride varnish, Outcomes Patient-
sealants and radiographs, rate of Centredness
extractions, endodontics, patient Timeliness
reattendance and patient
satisfaction
Dental Quality Alliance Adult 3 Process indicators of the evaluation Process Effectiveness Face validity gained through
Measures49 and ongoing care of patients with consensus of members. Data
periodontitis and provision of element and convergent validity
topical fluoride in patients with testing undertaken
elevated risk
Dental Quality Alliance 12 Measures of the utilisation of Process, Effectiveness RAND-UCLA method used to
Paediatric measures50 services; provision of sealants, Outcomes gain consensus of face validity
fluoride, prevention, treatment; of measure concept. Data
continuity of care; emergency element collection validity
department visits and follow-up assessed using Kappa statistics
cost
Dental Quality alliance 2 Measures of utilisation of Process Effectiveness Face validity gained through
Electronic Paediatric preventive and treatment services consensus of members. Data
measures51 element and convergent validity
testing undertaken
Child and adolescent Health 3 US national survey. Measures of Process, Effectiveness Not reported
Measurement Initiative utilisation of treatment services, Outcomes
National Survey of Children’s preventive services and presence
Health52 of toothache, bleeding gums,
decay and cavities
Child and adolescent Health 2 US national survey, assessment of Process Effectiveness Not reported
Measurement Initiative need and utilisation of preventive
National Survey of Children services
with Special Health Care
Needs, 2009/201053
National Network for Oral 15 Practice based dashboard to Structure, Effectiveness Not reported
Health Access Dental measure caries at recall, risk process Efficiency
Dashboard54 assessment, provision of sealants, and Patient-
topical fluoride, self-management outcome centredness
goal setting and review,
completion of treatment plans,
recall rates, recommendations,
and practice finances
Agency for Healthcare 21 National patient survey to assess Outcomes Patient- Not reported
Research and Quality Patient patient’s assessment of care from centredness
Experience Measures for the dentist and staff, access to dental Timeliness
CAHPSâ Dental Plan care, dental plan costs and
Survey55 services and patient satisfaction
Australian Council on 13 Measures of use of radiographs in Process, Effectiveness Not reported
Healthcare Standards56 new patients, retreatment rates, Outcomes
extraction of deciduous teeth,
complications following
extractions

(continued)

© 2018 FDI World Dental Federation 257

Byrne et al.

Table 2 continued
Measurement collection Items Description of measure Domains Dimensions Validation
(n)

California Department of 15 Measures of the use of preventive Process Effectiveness Not reported
Health Care Services57 services, sealants, fluoride varnish,
treatment services, continuity of
care
Indian Health Service58 3 Measure of receipt of topical Process, Effectiveness Not reported
fluoride dental sealants and access Structure
to oral health care
HRSA HIV/AIDS bureau 5 Measures of provision of oral Process Effectiveness Not reported
performance measures59 health education, periodontal
screening, treatment planning and
completion and taking dental and
medical history in patients with
HIV
HRSA Oral Health Quality 9 Treatment plan completion, use of Process Effectiveness Not reported
Improvement initiative60 services, provision of oral health
education, sealants, fluoride,
periodontal screening
Q-METRIC61 1 Measure of availability of services Structure Effectiveness Not reported
CMS-146 Measures62 7 Measures of use of dental services, Process Effectiveness Not reported
preventive services, treatment
services, sealant
MCH Title V National 3 Measure of percentages of: Process Effectiveness Not reported
Performance Measure for children with decay/cavities,
Oral Health Summary63 pregnant women receiving dental
care and children receiving
preventive dental care
Oral Health Disparities 17 Measures of rates of perinatal and Process Effectiveness Not reported
Collaborative Pilot early childhood caries, treatment Timeliness
Measures64 plan construction and completion,
paediatric dental examination and
treatment plan. Fluoride varnish
application, continuity of care
and fluoride assessment
Permanente dental associates65 32 Measures of use of fluoride, Process, Effectiveness Not reported
sealants, clinical incidents, Outcomes Patient-
examination rate, continuity of centredness
care, specialist care referral, Safety
percentage of specialty care Efficiency
completed by general dentist
NCQA 2017 State of Health 1 Measure of Medicaid members Process Effectiveness Not reported
Care Quality HEDIS measure who attended for a dental visit
annual dental visits66
Denplan Excel Patient Survey67 12 Patient-reported outcome measures Outcomes Patient- Not reported
of satisfaction with their dental centredness
health and satisfaction with their
dental care provision
Denplan Excel Quality 129 122 Checklist-style questions, Structure, Safety Not reported
programme68 rating of aspects of the structures Process Effectiveness
and processes of dental care Efficiency
delivery against quality standards.
Seven percentage measures of
process

Consumer Assessment of Healthcare Providers and Systems, CAHPS; Centers for Medicare & Medicaid Services, CMS-146; the Healthcare
Effectiveness Data and Information Set, HEDIS; Health Resources & Services Administration, HRSA; Maternal and Child Health, MCH;
National Committee for Quality Assurance, NCQA; National Institute for Health and Care Excellence, NICE; Quality Measurement, Evalua-
tion, Testing, Review and Implementation Consortium, Q-METRIC.

remaining outcome measures included measures of
longevity of restorations, rates of complications and
new disease presence at recall. In addition, 26.8%
(96/357) of the measures assessed structure. Of these
96 measures, 84 (87.5%) were derived from the ‘Den-
plan Excel’ quality measures, which quantified provi-
sion of equipment and staff within practices. The
measures predominantly assessed dimensions of
258
effectiveness, patient-centredness, safety and timeliness
of treatment. There were few measures of efficiency
or equity.
Quality measures gap analysis
The common themes identified in both the peer-
reviewed and grey literature measures are compiled in
© 2018 FDI World Dental Federation
 Table 3 Classification of all Peer-Reviewed and Grey Literature measures identified according to dimensions and domains
Structure
Dimensions
Safe Dentist : Nurse ratio
Evidence of staff training/certification
Evidence of ensuring that suppliers/contractors are
certified
Building set up to allow decontamination away from
clinical areas
© 2018 FDI World Dental Federation
Evidence of complaints handling procedures
Evidence of data protection and handling procedures
Cleanliness of practice
Evidence of practice infection-control measures
Use of single-use equipment where feasible
Certification of buildings and surgery safety
Evidence of medical emergency equipment
Effective
259
Domains
Process Outcome
Recording of medical history Patient satisfaction with cleanliness of facilities
Evidence of incident reporting being carried out Patient satisfaction with quality improvement initiatives
Number of serious incidents
Percentage of patients receiving oral health examination Patient rating of comfort in daily function
Percentage of patients receiving soft-tissue screening Patient rating of comfort during visit
Percentage of patients receiving emergency treatment Patient rating of ease to eat
Percentage of patients receiving planned treatment Patient rating of appearance of teeth
Percentage of patients receiving preventive advice Patient rating of comprehensiveness of examination/
treatment
Number of patients having radiographs taken Patient satisfaction with treatment received
Percentage of patients receiving dental follow-up after emergency Patient rating of quality of treatment
department visit for dental cause
Extraction to endodontics ratio Periodontal health: number of sites with bleeding on
probing
Evidence of caries and periodontal risk assessment being carried out Caries: number of decayed teeth
Percentage of patients receiving treatment for caries Caries: prevalence of early childhood caries
Prevention: fillings ratio Caries: new caries at recall of patient
Number of referrals to medical care Number of patients who are caries free
Number of referrals to secondary dental care Plaque on children’s teeth
Percentage of patients with a recording of Basic Periodontal Referral to secondary care for paediatric tooth
Examination extraction
Percentage of patients having comprehensive periodontal examination Emergency department visits from dental-related cause
Percentage of patients with history of periodontitis undergoing course of Patient-reported oral health-related quality of life
periodontal therapy
Percentage of patients with fluoride needs assessment Proportion of endodontic teeth that required
retreatment
Percentage of patients receiving preventive advice Proportion of sealants that require retreatment
Provision of fissure sealants in high-risk groups Number of deciduous teeth extracted
Provision of fluoride therapy in high-risk groups Complications following treatment
Extractions following endodontics
Proportion of fillings that subsequently required
retreatment/endodontics/extraction
Longevity of restorations
(continued)
Systematic review of quality measures
 Table 3 continued

260
Domains

Structure Process Outcome

Byrne et al.

Patient- Percentage of patients with named regular dentist Evidence of assessment of needs Patient satisfaction with communication – listening to
centred patient concerns
Access to hygienist Development of personalised treatment plans Patient satisfaction with communication – showing
concern
Access to Out of Hours care Setting self-management goals for patients Patient satisfaction with communication – explaining
treatments
Comfort of dental practice Time spent with patients Patient satisfaction with communication – treatment/
preventive advice
Aesthetics of dental practice Percentage of patients seeing same dentist/dental team at consecutive Patient satisfaction with communication – giving
visits appropriate level of information
Ease of payment Percentage of patients having treatment by their regular dentist Patient perception of dentist’s acceptance of them as a
person
Percentage of patients who are able to see their own dentist for Patient satisfaction with courtesy and respect of dental
emergency treatment team
Extractions/endodontics completed by patient’s general dentist Patient satisfaction with time spent with dental team
Length of treatment sessions (comfort to patient) Patient satisfaction with helpfulness of staff
Patient rating of ‘atmosphere’ of dental environment
Percentage of patients who would recommend to friend
Patient rating of trust
Patient satisfaction of dental team’s ability to respond
to their needs
Patient satisfaction with written information
Patient satisfaction with dentist
Patient rating of comfort of treatment
Patient-reported pain
Patient retention – number of patients who stay with
practice over time period
Timely Percentage of group of interest who have access to Timeliness of treatment plan completion Patient satisfaction with waiting times – to get standard
dentist appointment
Percentage of group of interest who have access to Timeliness of administrative claims Patient satisfaction with waiting times – to get
oral health education emergency appointment
Patient satisfaction with waiting times – in surgery
Proportion of high-risk patients who have been able to
access dentist
Efficient Generalist: specialist ratio in primary care Patient satisfaction with cost
Quality of interpersonal relationships between Patient rating of structure of dental appointments
members of dental team
Dental team satisfaction with their leadership Percentage of treatment plans completed
Dental team satisfaction with their ability to make Number of patients failing to attend
changes
Responsiveness of practice and team to making Percentage of patients reattending within 3 months
changes
Stress of team members within dental practice Average cost of treatment per patient
Use of modern equipment Number of dental encounters/hour
Longevity of restorations
Equity Evidence of local arrangements to assess health needs Percentage of group of interest that receive preventive advice/treatment Patient perception of dentist’s acceptance of them as a
in non-dental setting person
Local arrangements to identify high needs groups Patient rating of ease of access
Local arrangements to ensure access for high-needs
groups
Ease of access – car parking, disabled access

© 2018 FDI World Dental Federation


Table 3. This table identifies the broad constituent ele-
ment of quality that the measure attempts to capture
(IoM Dimensions) and the nature of the measure (Don-
abedian’s Domains). The categorisation of domain refers
to whether the measure assesses the structures of dental
care delivery, the processes that are undertaken or out-
comes that result from the delivery of care. As such, a
measure of the provision of a treatment or preventive
programme to a population is categorised as a process
measure. This analysis shows a proliferation of measures
developed for the assessment of process and outcomes
within the dimensions of effectiveness and patient-cent-
redness. Outcome measurement is predominantly
achieved via patient satisfaction measures. Significant
gaps in measures across the domains and dimensions of
quality are evident.
DISCUSSION
This systematic review describes 11 measure collections
(167 total measures) from the peer-reviewed literature
and 24 measure collections (357 total measures) from
the grey literature that may be used to assess quality in
primary care dentistry. This study is the first known
review of quality measures in primary care dentistry
that uses a systematic review design, with the use of a
priori inclusion and exclusion criteria.
Despite the structured searching methodology, it is
difficult to ensure that a comprehensive list of measures
has been captured, particularly those which appear in
the grey literature. The pace at which new measures are
being developed outside the peer-reviewed literature
means that further measures are likely to have been
produced since searching was completed. Whilst this
search may not include every measure that is available,
it does display the major trends of how quality is cur-
rently measured and therefore viewed by the dental
profession. Only English language sources were used,
as the cost associated with the translation of foreign
language measures and papers would be prohibitive.
This provides a view of quality measurement domi-
nated by developed countries. Quality measures will
necessarily reflect the context and the priorities in
which care is delivered; measures formulated in the
developed world may not be as relevant in less devel-
oped communities. FDI called for an international con-
sensus on understanding quality in dentistry2, and the
influence of local context and priorities should not be
underestimated in working towards this goal.
Using valid and reliable tools to measure quality is
vital in order to support day-to-day quality assessment
and improvement of dental care. The 11 measure sets
from the peer-reviewed literature22–24,26,27,29,30,31,32,33,38
and three measure sets from the grey literature50,56,57
represent measures available to researchers to assess
dimensions of quality in relation to primary care
© 2018 FDI World Dental Federation
Systematic review of quality measures
dentistry. The majority of these measures showed
acceptable levels of internal validity; however, their
usefulness in delivering a clear picture of quality and
to support quality improvement is unclear.
The gap analysis categorised the measures according
to the IoM dimensions of quality and identified impor-
tant areas of care in which specific dental measures were
absent. Some of these gaps are possibly populated by
measures used successfully in other areas of health care.
It could also be the case that the IoM dimensions fail to
describe significant elements of quality that are impor-
tant to dentistry, such as cosmetic care, functional
improvement and the discomfort and anxiety associated
with dental procedures. Further dimensions described in
the literature include tangibility26,70, responsiveness26,70,
empathy26,70, accessibility7,12, coordination and continu-
ity of care12, comprehensiveness12, technical quality5,
acceptability71, legitimacy71, optimality71, relevance72,
appropriateness11 and ‘caring function’11.
The majority of the measures within the grey litera-
ture focussed on processes of care. Core themes of flu-
oride prescription, provision of fissure sealants and
dental attendance were identified from this search.
However, without corresponding measures of result-
ing outcomes, these process measures may have lim-
ited utility19. The majority of outcome measures
identified in this search assessed patient satisfaction.
However, a review of patient satisfaction measures
suggests that these are highly affected by disconfirma-
tion and attribution bias and are inherently unreli-
able73. It has been suggested that the patient’s
perception of technical competence is based on the
communication and caring nature of the dentist rather
than the work they actually carry out33. As the pri-
mary stakeholders of primary care dentistry, it is intu-
itively important that patients are provided with a
service that provides satisfaction; however, measures
of patient satisfaction give only a limited indication of
the overall quality of care provided.
Consideration also needs to be given to the reasons
for collecting data on quality; the various stakeholders
in primary dental care have different priorities for
their use. For example, policy makers may want to
use such data to improve equity and access for a
defined population. Dentists may wish to use quality
measurement to fulfil a personal and professional
desire to improve the care for their patients or as a
way of marketing themselves or their practice.
Patients may wish to use measures to compare the
quality of care provided by different dentists. Provi-
ders of dental care may wish to use quality data for
performance management of their dentists or as a
way of remunerating and incentivising their dentists.
Linking quality improvement to remuneration runs
the risk of inducing unintended behaviour change,
leading to alterations in the provision of care74; this
261
Byrne et al.
may include services de-registering high-risk patients
who threaten to lower their quality rating.
The majority of measures currently used within pri-
mary care dentistry have been developed by private
companies, such as insurers or corporate care provi-
ders, and are not published in peer-reviewed journals.
Two issues arise from this: first, time and resources
are being used in the development of measures that
have already been developed elsewhere; and, second,
measures are being used without the scrutiny of the
wider scientific community. The authors believe that
international collaboration is required to develop
valid and reliable measures that can be applied across
a range of contexts.
CONCLUSIONS
This research has highlighted the lack of valid, reliable
measures used to assess quality. Current efforts in pro-
ducing quality measures are being conducted with little
academic grounding, leading to measures of limited
validity and utility that fail to capture some key elements
of quality. International collaboration is required to
agree on a definition of quality and a shared understand-
ing of what quality means for dentistry. Consensus
would guide the production of valid, reliable measures
within an agreed framework for the benefit of patients.
Acknowledgements
No further acknowledgements are made. No financial
support was provided for this project.
Competing interests
The authors have no competing interests to declare.
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Correspondence to:
Matthew Byrne,
NIHR Academic Clinical Fellow in Primary Care
Dentistry,
Division of Dentistry,
School of Medical Sciences,
Faculty of Biology, Medicine and Health,
University of Manchester,
Oxford Road,
Manchester M13 9PL, UK.
Email: matthew.byrne-6@postgrad.manchester.ac.uk
264
APPENDIX 1. SEARCH STRATEGY
The Following search strategy was used in MEDLINE:
1 exp *”Quality of Health Care”/
2 ((quality or performance$ or satisf$) adj5 (indicat
$ or activit$ or framework$ or tool$ or matrix or
matrice$ or measure$ or guideline$ or accreditat$
or indices or index or certificat$ or regulat$ or
assur$ or standard$ or control$ or audit$ or met-
ric or improv$ or criteri$ or assess$ or valid$ or
scale$ or checklist$)).ti,ab. not (quality adj2
life).mp. [mp=ti, ab, sh, hw, ot, kw, bt, id, cc, ac,
de, md, sd, so, pt, an, tn, dm, mf, dv, fx, nm, kf,
px, rx, ui, sy]
3 1 and 2
4 exp Dentists/
5 ((dentist$ or (dental adj5 practitioner$)) not stu-
dent$).ti,ab.
6 exp Dental auxiliaries/
7 ((dental and (hygienist$ or therapist$)) not student
$).ti,ab.
8 (“oral health practitioner” or “dental assistant$”
or “dental auxil$” or “dental hygiene practitioner
$” or “community dental health co-ordinator$”
or “oral health co-ordinator$”).ti,ab.
9 4 or 5 or 6 or 7 or 8
10 3 and 9
11 Remove duplicates from 10
© 2018 FDI World Dental Federation