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PubMed for Dental Research: Literature Review

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Section Objective

What is a literature review, clearly stated research question, search terms, searching worksheets, boolean and / or.

The content in the Literature Review section defines the literature review purpose and process, explains using the PICO format to ask a clear research question, and demonstrates how to evaluate and modify search results to improve the accuracy of the retrieval.

A literature review seeks to identify, analyze and summarize the published research literature about a specific topic.  Literature reviews are assigned as course projects; included as the introductory part of master's and PhD theses; and are conducted before undertaking any new scientific research project.

The purpose of a literature review is to establish what is currently known about a specific topic and to evaluate the strength of the evidence upon which that knowledge is based. A review of a clinical topic may identify implications for clinical practice. Literature reviews also identify areas of a topic that need further research.

A systematic review is a literature review that follows a rigorous process to find all of the research conducted on a topic and then critically appraises the research methods of the highest quality reports. These reviews track and report their search and appraisal methods in addition to providing a summary of the knowledge established by the appraised research.

The UNC Writing Center provides a nice summary of what to consider when writing a literature review for a class assignment. The online book, Doing a literature review in health and social care : a practical guide (2010), is a good resource for more information on this topic.

Obviously, the quality of the search process will determine the quality of all literature reviews. Anyone undertaking a literature review on a new topic would benefit from meeting with a librarian to discuss search strategies. A consultaiton with a librarian is strongly recommended for anyone undertaking a systematic review.

Use the email form on our Ask a Librarian page to arrange a meeting with a librarian.

The first step to a successful literature review search is to state your research question as clearly as possible.

It is important to:

• be as specific as possible
• include all aspects of your question

Clinical and social science questions often have these aspects:

• P eople/population/problem
• I ntervention
• C omparisons (not always included)

If the PICO model does not fit your question, try to use other ways to help be sure to articulate all parts of your question. Perhaps asking yourself Who, What, Why, How will help.

Example Question:  Do electric toothbrushes work as well as or better than manual toothbrushes to remove plaque when used by children?

Note that this question fits the PICO model.

• Population: Children
• Intervention: Electric toothbrush
• Comparison: Manual toothbrush
• Outcome: Plaque removal

A literature review search is an iterative process. Your goal is to find all of the articles that are pertinent to your subject. Successful searching requires you to think about the complexity of language. You need to match the words you use in your search to the words used by article authors and database indexers. A thorough PubMed search must identify the author words likely to be in the title and abstract or the indexer's selected MeSH (Medical Subject Heading) Terms.

Start by doing a preliminary search using the words from the key parts of your research question.

Step #1: Initial Search

Enter the key concepts from your research question combined with the Boolean operator AND. PubMed does automatically combine your terms with AND. However, it can be easier to modify your search if you start by including the Boolean operators.

children AND electric toothbrush AND manual toothbrush AND plaque removal

The search retrieves a number of relevant article records, but probably not everything on the topic.

Step #2: Evaluate Results

Use the Summary drop down in the upper left hand corner of the results page to change the display to show all the Abstracts.

Review the results and move articles that are directly related to your topic to the Clipboard .

Go to the Clipboard to examine the language in the articles that are directly related to your topic.

• look for words in the titles and abstracts of these pertinent articles that differ from the words you used
• look for relevant MeSH terms in the list linked at the bottom of each article

The following two articles were selected from the search results and placed on the Clipboard.

Here are word differences to consider:

• Initial search used Children. MeSH Terms use Child.
• Initial search used Electric Toothbrush. Article titles use Battery-Powered, Powered. Related word from MeSH Terms is Electricity.
• Initial search used Manual Toothbrush. Article title uses Manual Toothbrushes. Related word from MeSH is Toothbrushing.
• Initial search used Plaque Removal. Article titles use this exact phrase. MeSH Terms use Dental Plaque combined with Therapy, Prevention, Control.

With this knowledge you can reformulate your search to expand your retrieval, adding synonyms for all concepts except for manual and plaque.

#3 Revise Search

Use the Boolean OR operator to group synonyms together and use parentheses around the OR groups so they will be searched properly. See the image below to review the difference between Boolean OR / Boolean AND.

Here is what the new search looks like:

(child OR children) AND (electric OR electricity OR battery OR power OR powered) AND manual AND (toothbrush OR toothbrushes OR toothbrushing) AND plaque AND (removal OR remove OR therapy OR prevention OR control)

• Search Worksheet Example: Manual vs. Electric Toothbrush
• Search Worksheet
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• Last Updated: Sep 29, 2022 3:41 PM
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• Research article
• Open Access
• Published: 05 June 2014

Patient-centred care in general dental practice - a systematic review of the literature

• Ian Mills 1 , 6 ,
• Julia Frost 2 ,
• Chris Cooper 3 ,
• David R Moles 4 &
• Elizabeth Kay 5  

BMC Oral Health volume  14 , Article number:  64 ( 2014 ) Cite this article

12k Accesses

56 Citations

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Metrics details

Delivering improvements in quality is a key objective within most healthcare systems, and a view which has been widely embraced within the NHS in the United Kingdom. Within the NHS, quality is evaluated across three key dimensions: clinical effectiveness, safety and patient experience , with the latter modelled on the Picker Principles of Patient-Centred Care (PCC). Quality improvement is an important feature of the current dental contract reforms in England, with “patient experience” likely to have a central role in the evaluation of quality. An understanding and appreciation of the evidence underpinning PCC within dentistry is highly relevant if we are to use this as a measure of quality in general dental practice.

A systematic review of the literature was undertaken to identify the features of PCC relevant to dentistry and ascertain the current research evidence base underpinning its use as a measure of quality within general dental practice.

Three papers were identified which met the inclusion criteria and demonstrated the use of primary research to provide an understanding of the key features of PCC within dentistry. None of the papers identified were based in general dental practice and none of the three studies sought the views of patients. Some distinct differences were noted between the key features of PCC reported within the dental literature and those developed within the NHS Patient Experience Framework.

Conclusions

This systematic review reveals a lack of understanding of PCC within dentistry, and in particular general dental practice. There is currently a poor evidence base to support the use of the current patient reported outcome measures as indicators of patient-centredness. Further research is necessary to understand the important features of PCC in dentistry and patients’ views should be central to this research.

Peer Review reports

Patient-centred care (PCC) is recognised as a key dimension of quality within health care according to the Institute of Medicine [ 1 ]. The importance of patient-centred care has also been recognised by the Australian Commission on Safety and Quality in Healthcare [ 2 ], the King’s Fund [ 3 ], Agency for Healthcare Research and Quality [ 4 ] and the Picker Institute [ 5 ]. PCC is relevant throughout the world irrespective of the system of healthcare or the cultural differences [ 6 ]. The International Alliance of Patients’ Organizations (IAPO) represents patients of all nationalities and has a vision to ensure delivery of patient-centred care around the world.

Health services research suggests that PCC leads to enhanced patient satisfaction, improved outcomes, enhanced health status and reduced utilization of care [ 7 – 10 ]. It is also claimed that PCC can result in greater work satisfaction for professionals and reduced levels of medical litigation [ 11 ]. Such benefits are extremely desirable for patients, health professionals and commissioners and fully justify the current enthusiasm for the delivery of patient-centred care.

Recent healthcare reforms in the UK have focussed heavily on quality management, with assessment of quality incorporated into both primary and secondary care services. Quality has been defined in terms of patient safety, clinical effectiveness and the experience of patients [ 12 ]. These features have laid the foundations for indicators which will be used to measure improved quality of healthcare [ 13 ] with patient feedback playing an increasingly important role in measuring the level of quality delivered [ 14 , 15 ].

PCC is just as relevant within dentistry, although this may not be reflected in terms of the volume of current literature. The FDI World Dental Federation recognises the importance of quality assessment and improvement in dentistry, but reports that there is considerable variation across member countries in the approach to quality management [ 16 ]. The lack of an agreed definition of “quality in dentistry” is reported as a barrier to measuring quality and this is highlighted as key to future developments. The Dental Quality Alliance (DQA) is a group of professional organisations in the United States with a mission of advancing performance measures as a means to improving oral health, patient care and patient safety [ 17 ]. The DQA have embraced the definition and domains of quality as described by the Institute of Medicine and focus substantially on the importance of patient-centred care within dentistry [ 1 ].

In the UK, provision of quality care within the general dental services has been a long held aspiration, but designing an effective method of remuneration to ensure that this is delivered has proved a considerable challenge. In 2006 a new system was introduced which aimed to improve patient access, promote prevention and deliver quality. It is now generally agreed that the system failed to deliver on its key objectives [ 18 , 19 ]. These failings have been recognised [ 20 , 21 ] and there is now a greater emphasis on ‘quality’ in the UK. In February 2014 the Chief Dental Officer for NHS England launched “Improving Oral Health – A Call to Action” aimed at developing a long-term strategic plan for NHS dentistry. One of the key objectives within this plan is the delivery of high quality dental care [ 22 ]. A Dental Quality and Outcomes Framework (DQOF) to measure quality has already been developed in England and is currently being evaluated [ 23 ]. The current DQOF measure is based around 3 dimensions of quality: Clinical Effectiveness , Patient Experience and Safety.

• Patient-centred care

The term ‘patient-centred care’ is widely used but poorly understood. This can create confusion, where individuals may have vastly different values, expectations and perceptions of what is successful patient-centred care [ 24 ]. Various authors have attempted to define PCC in the medical, nursing and psychiatry literature [ 25 – 27 ] including such authorities as the Picker Institute, the Planetree Foundation, The King’s Fund and the Institute of Medicine [ 1 , 3 , 5 , 28 ]. PCC has also been studied extensively within primary care with benefits considered and definitions proposed [ 8 , 29 , 30 ].

There is widespread acceptance that a “patient-centred” approach to patient care is beneficial, although it is less clear what “patient-centred” actually means. Stewart et al [ 27 ]. recognised this and stated that;

“Patient-centredness is becoming a widely-used but poorly understood concept in medical practice. It may be most commonly understood for what it is not – technology-centred, doctor-centred, hospital-centred, disease-centred” [ 27 ]

Despite the apparent confusion around the term PCC, Stewart is confident that there is strong agreement internationally based on her own work and that of Little et al. [ 24 , 27 ]. Stewart et al. described six interactive components which formed the basis of the patient-centred clinical method, which supported a comprehensive and holistic approach to care [ 31 ]. This was further developed by the Picker Institute and subsequently the seminal publication by the Institute of Medicine in 2001 – “Crossing the Quality Chasm” [ 1 ].

In the UK, the NHS Patient Experience Framework [ 32 ] provides guidance on the elements of care considered to be critical to the patient experience based on primary research. The framework represents the key dimensions of PCC and is closely aligned to the Picker Principles of Patient-Centred Care [ 5 ]. The Department of Health state that the Patient Experience Framework “ provides a common evidence based list of what matters to patients ”.

There are many definitions of PCC, but the Institute of Medicine version seems to have gained widespread acceptance.

“provision of care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” [ 1 ]

In view of the importance of PCC, we considered that a systematic literature review was indicated to assess the current literature within dentistry.

Aim of literature review

A systematic review of the literature was undertaken with the following key objective:

What core elements of patient-centred care have previously been described in relation to dentistry that are based on primary research?

Search strategy

A methodical approach based on the Centre for Reviews and Dissemination guidance for undertaking reviews in health care [ 33 ] was adopted using electronic databases to search the literature, supplemented by hand searching and cross-referencing [ 34 ] (Additional file 1 ).

Databases searched included PubMed, MEDLINE, PsychINFO, SocINDEX, Dentistry & Oral Sciences Source, The Cochrane Library and CINAHL. Search terms were based on key words and phrases such as ‘patient-centred care’, ‘person centred care’, ‘person focussed care’, ‘oral’, ‘dental’ and ‘dentistry’. The PCC terms and dental terms were then combined as a separate search to identify articles associated with PCC in dentistry. MeSH terms were also used for both ‘patient-centred care’ and ‘dentistry’, and details of the search criteria are demonstrated in Additional file 2 .

Additional databases were subsequently included within the search and these involved NHS Evidence, HMIC, Cochrane Oral Health and Web of Science. Further searching was conducted on the internet via search engines such as Google and Google Scholar, and specific websites were used to search for articles or policy documents including the Kings Fund, Picker Institute, Planetree Foundation and the Institute for Patient and Family-Centered Care.

It is recognised that protocol driven search strategies do not always manage to identify all the relevant sources of literature, irrespective of the number of databases included within the search [ 35 ]. The protocol driven search strategy was therefore supplemented with additional search techniques including one generation backward searching, forward citation chasing and personal communication [ 34 ]. These additional searches identified a number of additional papers, which had not been found in the original search of the main databases. This fully justified our comprehensive approach to the search strategy and highlights the importance of including additional search techniques to identify relevant literature.

Inclusion/Exclusion

Inclusion/exclusion criteria were applied to the articles identified from the literature search and the details are included in Table  1 . We were specifically interested in assessing the evidence base for PCC within general dental practice and consideration was given to limit the literature search to such studies. However, it was felt that this would be too specific and potentially exclude some relevant publications. A decision was therefore made to include all literature investigating the concept of “patient-centred care” within any aspect of dentistry.

The focus of this review was on determining the evidence base to support an understanding of PCC within dentistry. It was therefore solely concerned with primary research describing the dimensions or features of PCC. All forms of publication or article were included irrespective of the study design, the setting or the demographics. Opinion articles, reviews and articles reporting non-original research were excluded. Additional inclusion criteria were applied to ensure that articles were available in English language and published between January 1970 and February 2013. It was considered unnecessary to obtain articles prior to 1970 as it is generally accepted that the concept of PCC was originally introduced by Enid Balint as “patient-centred medicine” in 1969 [ 36 ].

A two-stage process was used during screening. Stage 1 involved initial screening of the title and abstract against the inclusion criteria. At this stage if there was any degree of uncertainty over the applicability of the publication it was automatically included and the full text article assessed. Stage 2 involved screening of the full text articles against the predetermined inclusion criteria with eligible studies for review identified at this stage. The inclusion criteria were applied as an absolute, and all aspects of the criteria needed to be fulfilled for inclusion within the review. The key requirements for inclusion were:

 Publication of primary research study within peer-reviewed journal

 Research related to dentistry

 Research findings describing a conceptual framework for patient-centred care or its constructs.

Search outcome

Our search yielded 203 citations. Of these 203 papers, the initial electronic search accounted for 162 articles, with additional searching techniques identifying the remaining 41 papers. At Stage 1 screening, the 203 papers were assessed by the lead author (IJM) against the pre-determined selection criteria based on the information available in the title and abstract, if available. One hundred and fifty five papers were excluded at this stage, as they were not relevant to the area of research interest. The full text articles of the remaining 48 papers were obtained and assessed (Stage 2). Assessment of each article against the screening criteria was undertaken by the first author (IJM) with the advice and support of the rest of the research team. These 48 papers originated from various countries although a significant proportion of the literature (54%) was published from North America, with a further 27% from the UK.

Of these 48 papers, only 3 publications were considered to have met the inclusion criteria in full and were directly relevant to the aims of this literature review. Of the potentially eligible 48 citations, 29 were based on personal opinion or review and encompassed a wide range of topics where the term “patient-centred” had been applied. These articles were excluded as they did not undertake primary research into PCC in relation to dentistry or review the findings of such research. The remaining 19 articles undertook primary research with 11 papers using quantitative methodology and the remaining 8 utilising qualitative methods. Sixteen of these articles (11 quantitative and 5 qualitative) did not meet the inclusion criteria in terms of their research aims and were subsequently excluded.

Quality appraisal

There are various quality appraisal tools which can be used to assess the quality of the literature depending on the type of research undertaken. There is no universally agreed quality appraisal tool for qualitative research [ 37 ], but the Critical Appraisal Skills Programme (CASP) for qualitative research [ 38 ] is considered to be a suitable tool for quality appraisal in the oral health field [ 39 ]. The quality appraisal of the 3 eligible papers was undertaken by the lead author (IJM) in discussion with the other authors. The quality assessment was based on aspects of the research team, study methods, context of the study, findings, analysis and interpretations [ 40 ].

Data extraction

Data extraction was primarily concerned with assessment of the evidence base of the literature and identification of the dimensions or features of PCC, which had been described. The features of PCC described within the texts were coded and examined for similarities and variations between each other. They were also compared to existing seminal texts [ 1 , 5 ] reporting dimensions of PCC within the broader literature.

Almost two-thirds of the literature identified following stage 1 screening was based on opinion or review, with the remainder of the articles published as primary research. Many of the opinion papers identified within this literature review describe features of PCC as reported by Gerteis [ 41 ] and published in the seminal text “Crossing the Quality Chasm” by the Institute of Medicine in 2001 [ 1 ]. The opinion papers identified within this literature review reveal a strong correlation with the dimensions of PCC as described by the Institute of Medicine, although it is important to appreciate that the views expressed have not been formulated on evidence based dental research.

Of the nineteen primary research papers, only three described PCC and its dimensions through original research. The other sixteen research papers were excluded as they did not explore the nature of PCC. Eleven of the excluded articles were concerned with investigation of “patient-centred” outcome measures rather than PCC and were therefore not relevant to this review. Four articles assessed the delivery of PCC, or a dimension thereof, by using measurement tools previously described in the medical literature. The remaining article used the term “patient-centred” purely as a descriptor and was not concerned with the investigation of any aspect of PCC (See Table  2 ).

Only 3 papers [ 42 – 44 ] fulfilled the predetermined inclusion criteria and provided data and evidence describing the key features of patient-centred care within dentistry. The literature review demonstrates that there have not been any published studies on patient-centred care within general dental practice. The 3 relevant papers are included in Table  3 with a brief summary of the nature of the study conducted and the key findings.

The three eligible papers all used qualitative research methods and were considered to be of acceptable quality in terms of methodology, analysis, interpretation and relevance when appraised using the CASP framework for qualitative research [ 38 ]. A summary sheet providing an overview of the quality assessment is shown in Table  4 . None of the studies sampled patients to assess PCC, and instead favoured recruitment of dental care professionals as their participants. All three studies used semi-structured in-depth interviews to collect data, with Scambler [ 44 ] also using focus groups. Kulich used video to record consultations, and this information was then used to enrich the data, promote reflection by the dentist involved and stimulate discussion during the interview.

The first of the three papers, Kulich et al. [ 42 ], undertook research to identify the important elements of delivering a patient-centred approach while managing patients with dental anxiety. The research team used qualitative research methods based on semi-structured interviews and video recording of consultations. The participant group included 5 dentists specialising in the treatment of ‘odontophobia’, who were recruited by convenience sampling as part of the dental team working at a clinic treating ‘phobic’ patients in Sweden. Fifteen patients were recruited for treatment from the clinic waiting list and attended on two separate occasions, which provided the background for the interviews with the dentists responsible for their care. This resulted in a total of thirty interviews, which were audio-recorded and transcribed verbatim. The video recording was used to promote discussion and enrich the data provided during the interviews. The video data were not formally analysed, but were used in the style of “action research” to stimulate discussion during the interviews and encourage self reflection and verbalisation on the part of the participant dentist. The authors considered this approach to be beneficial and provided “significant impact” in the generation of data.

Grounded theory was used as the conceptual basis of the study and data were collected until saturation was considered to have been achieved. Content analysis was undertaken and a model of a patient-centred consultation developed. This was defined in terms of one overarching core principle - “ holistic perception and understanding of the patient” and two underlying categories of “the dentist’s positive outlook on people” and “the dentist’s positive view of patient contact”. The categories described were underpinned by the following aspects of care: empathy, equality, dignity, emotional understanding, respect and engagement .

The second paper, by Loignin and co-workers [ 43 ], examined the concept of PCC within a different context. They investigated what skills and approaches dentists in Canada used to overcome barriers to dental care for people living in poverty. They undertook a qualitative study with a group of dentists experienced in delivering care to people living in poverty in Canada. Data were collected by conducting semi-structured interviews with 8 dentists identified as a subgroup of an existing research sample. The subgroup was recruited based on their experience of treating patients living in poverty within Montreal. Content analysis was undertaken which revealed three main themes: “ dentists’ experiences with low income patients, perception of poverty and strategies to overcome difficulties with this clientele.” The authors reported the key aspects of successful delivery of dental care to this group of patients and although they use the term “socio-humanistic approach”, they also refer to this as a “patient-centred approach” within the text. The key features highlighted are:

  Understanding patients’ social context

  Taking time and showing empathy

  Avoiding moralistic attitudes

  Overcoming social distances

  Favouring direct contact with patients

Finally, Scambler [ 44 ] conducted a qualitative study to explore attitudes of staff within Special Care Dentistry towards disability and the provision of dental care. The research was concerned with the social model of disability in terms of dentistry and although the study was not directly concerned with PCC, the findings are closely linked. The authors report that patient-centred care was “at the heart of the model”, and PCC is highlighted as one of the key themes to emerge from the research. The study involved recruitment of thirty staff from a Salaried Dental Service Department in London (England), which included clinicians, dental care professionals and administrative staff. Data were collected through interviews and focus groups and initially analysed thematically. Retroductive analysis was then conducted using a framework based on the social model approach to disability. The authors describe several key features of PCC and detail the importance of a holistic approach allowing delivery of individualised care by providing appropriate information and support. The importance of trust, time and communication were also highlighted as important factors in providing patient-centred care.

There are a number of similarities between the three papers in terms of the research topic, sampling methods, data collection and findings. However there are contrasting styles in terms of data analysis, particularly between Kulich and Scambler. Kulich used grounded theory to analyse their data and develop theory generation. Data collection, coding and analysis were conducted simultaneously and continued until saturation had been reached. In contrast, Scambler used mid range theory with retroductive analysis. The objective was to undertake theory testing in contrast to Kulich who was theory generating. Although very different in approach, both studies provide insight into the important features of PCC according to the participant samples.

There was a degree of commonality between the findings of the three studies, with each highlighting the need to treat the patient as a person or as an individual in their own right. This reflects the key principles of PCC as described by Gerteis [ 41 ]. Each article also reported the importance of a clear focus on delivering a holistic, non-judgemental approach which represented the findings of previous reports on PCC in other areas of healthcare. The importance of communication was highlighted as a key feature of PCC, and this also featured frequently within the rest of the dental literature. The three articles all detailed the importance of breaking down perceived barriers to allow establishment of a dentist-patient relationship through “direct contact”, “patient contact” or “overcoming social distance”.

Two of the eligible papers highlighted the importance of empathy and understanding, which was again representative of the overall dental literature. Other features that were also reported were the importance of information and support, individualised care, trust and the impact of time.

Certain aspects of PCC that feature within the rest of the dental literature have not been described within the evidence-based papers. These include patient satisfaction [ 45 – 47 ], oral health promotion/self care [ 48 ] and physical comfort [ 49 ].

The results across the three studies show a degree of congruity and tend to highlight similar themes within their findings. This could be indicative of a degree of conformity in terms of PCC across different areas of dentistry, or it could simply be due to the homogenous nature of the participant groups, the study design or the similarities in the area of research investigated.

The studies recruited dentists, dental care professionals and administrative staff to understand the key features of PCC, with none of them engaging with patients directly. This is considered by the authors to be a key finding of this literature review, and highlights the importance of understanding PCC from a “patients” perspective. Health professionals have a wealth of knowledge and experience, but ultimately it is patients’ views, which need to be considered and adequately represented when we wish to understand “patient-centred care”. This has recently been recognised by the Cochrane Collaboration with the importance of involving patients in developing “patient-centred outcome measures” highlighted as a key factor in delivering informed healthcare decisions [ 50 ].

The studies were not based in general dental practice and focussed on “specialised’ areas of dentistry concerned with the treatment of vulnerable patients. Although such patients may attend general dental practices for routine care, they are likely to have more specific needs, which are not necessarily representative of the rest of the population. It needs to be recognised that although the features identified within these studies could be highly relevant, there may be distinct differences within a group of patients attending a general dental practice. Kulich et al. suggested in their concluding remarks that their findings may be generalisable within the scope of treating dental phobic patients, but the basic principles “should also be applicable to wider areas of dentistry” when dealing with anxious patients.

The recurring themes within this limited body of literature highlight the importance of a humanistic, non-judgemental approach based around good communication, empathy and understanding. (See Tables  3 & 5 ) The need to see the patient as a person or as an individual in their own right was a strong theme throughout the research articles and aligns closely to the patient-centred clinical method (PCCM) described by Stewart et al. [ 31 ]. This framework is based on the concept that ill health has two components – disease and illness. Stewart et al. recognised that history taking and clinical examination provides information on the disease, but it is equally important to understand and appreciate the patient’s perspective and experience of the illness. An understanding and appreciation of the patient’s feelings can only be achieved by engaging with the patient through communication and developing the patient-doctor (dentist) relationship, and this was highlighted repeatedly within the three articles identified within this review. These concepts also reflect the findings within Kitson’s narrative review of the nursing literature [ 51 ] which described three main themes; patient involvement, relationship and context.

Despite a close correlation with previous work on PCC, some distinct differences within the dental literature are evident. The most obvious difference was the lack of emphasis within the dental literature on the dimensions of “involvement of family and friends”, “co-ordination and integration” and “physical comfort” as described within the Picker Principles of PCC [ 5 ], The NHS Patient Experience Framework [ 32 ] and the Institute of Medicine [ 1 ].

“Involvement of family and friends” was not considered to be an important feature within dentistry, other than in relation to consent. In contrast, “Involvement of family and friends” is considered one of the most important features of PCC according to Cronin [ 52 ] who undertook a review of PCC in 2004.

“Co-ordination and integration” of care was not highlighted within the dental literature as an important feature of PCC, which may reflect the more solitary nature of work as a dentist compared to our medical colleagues who tend to work in larger teams. With the increasing development of skill mix, specialisation and team working, co-ordination and integration is likely to become an increasingly important feature within primary care dentistry.

“Physical comfort” did not feature as an important aspect of patient-centred care within the dental literature. This would appear surprising as fear of pain is considered to be a common barrier to dental attendance for a significant proportion of the population. As highlighted previously, sampling for the three research articles was restricted to dental care professionals with no patients selected as participants. It is conceivable that this aspect of patient-centred care may have featured if patients had been included within the interviews.

These differences highlight the importance of understanding the features of PCC within the contexts of setting, sampling and the area of health investigated. The dimensions described by the Picker Institute [ 5 ], the Institute of Medicine [ 1 ] and The Kings Fund [ 3 ] focus on the secondary care setting, predominately with in-patient care. This would explain the importance of “involvement of family and friends” and “co-ordination and integration”, which would be less relevant to the delivery of dental care in a general dental practice.

Little et al [ 24 ] investigated patient preferences in attending general medical practice, based on a questionnaire designed to assess patient-centredness. The authors identified three important domains of patient-centredness from the patients’ perspective: communication, partnership , and health promotion . Communication and partnership were key aspects reported in the dental literature, although health promotion did not feature. General dental practice may be considered to be more closely aligned to general medical practice than it is to secondary care in terms of continuity of care, familiarity and their role within the community. This will obviously be dependent on the practice, the setting and the healthcare system. There are, however, many differences between general dental practice and medical practice and one should not assume that the key features of PCC would be the same for both.

The importance of communication and relationship was highlighted repeatedly throughout the dental literature and would appear to be a cornerstone of PCC. The overarching theme of the features reported was around the importance of “soft skills” of the clinician. Empathy, equality and emotional understanding were considered to be particularly important and this would appear to support the work of Burke and Croucher [ 53 ], and Holt and McHugh [ 54 ] on patients’ views of the important features of a good dentist.

The primary aim of the general dental practitioner is to improve and maintain the oral health of their patients and this is normally based on a long term relationship rather than episodic care [ 55 ]. This relationship is crucial and success is based on trust, respect and mutual understanding [ 56 , 57 ]. Communication is key, but must not be considered as simply an act of giving and receiving information. Communication is about establishing a “connection” on a human level in order that we can understand the beliefs, needs and preferences of the individual. This is an important theme, which has been repeatedly identified within this literature review and highlights the importance of “putting the patient first” and taking a holistic approach to care.

Delivery of patient-centred care is an important aspect of providing quality dentistry, but there appears to be a poor understanding of the term within the existing literature. This paper demonstrates that there is only limited evidence to provide an understanding of patient-centred care within dentistry and the research, which has been published, does not relate to general dental practice.

The NHS Patient Experience Framework states that “ it is possible to apply a single generic framework....to a wide range of health conditions and settings .” [ 32 ] The results of this review, albeit from a limited evidence-base, would appear to indicate that there are some distinct differences within the domains of PCC in dentistry when compared to other areas of health. In view of this it may not be appropriate to simply use a generic medical framework to assess PCC as an effective indicator of quality in dentistry.

These findings are equally relevant on an international perspective, for countries striving to implement quality management systems within general dental practice. This lack of evidence-based research must be addressed if we wish to measure PCC within general dental practice and deliver quality improvement. Research needs to be undertaken within primary care and must be developed from a patients’ perspective if we wish to understand patient-centred care within dentistry.

Key findings

 Future research should ensure that a patient’s perspective of PCC is adequately represented.

 There is a lack of evidence to adequately understand PCC within dentistry.

 The evidence which is currently available on PCC in dentistry is not necessarily generalisable to general dental practice.

 Further research is necessary to understand the key features of PCC within general dental practice if we wish to use this as a quality indicator.

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Acknowledgements

We would like to acknowledge the support of the National Institute of Health Research (NIHR) who provide funding for the lead author as a part-time NIHR Academic Clinical Fellow in General Dental Practice at Peninsula Dental School.

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IJM was involved in all aspects of this review including the literature search, data extraction, quality appraisal and drafting the manuscript. CC provided advice, support and direction on the search strategy and contributed to the final draft of the paper. DRM, JF and EJK provided advice and support on all aspects of the systematic review including development of the protocol, screening, data extraction and editing the paper. DRM and JF were directly involved with quality appraisal, synthesis of the data and interpretation of the results. All authors read and approved the final manuscript.

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Mills, I., Frost, J., Cooper, C. et al. Patient-centred care in general dental practice - a systematic review of the literature. BMC Oral Health 14 , 64 (2014). https://doi.org/10.1186/1472-6831-14-64

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• General dental practice
• Systematic review

BMC Oral Health

ISSN: 1472-6831

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Top 100 cited systematic reviews and meta-analyses in dentistry

Affiliations.

• 1 Department of Endodontology, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.
• 2 Department of Dentoalveolar Surgery, Surgical Implantology & Radiology, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.
• PMID: 31418611
• DOI: 10.1080/00016357.2019.1653495

Objective: The purpose of the present study was to identify the 100 top cited systematic reviews and meta-analyses on dental journals so as to gain insight into the influential publications in dentistry. Material and methods: The Web of Science was used to comprehensively identify the 100 most cited papers without year and language restriction. Specific parameters regarding the title, journal, publication year, authors, country of origin, institution and university, collaborations, keyword analysis and field of study of each manuscript were retrieved. Results: The citations ranged from 642 to 140. The most productive years were 2008 and 2009. The majority of top cited papers were published in Clinical Oral Implants Research and Journal of Clinical Periodontology. The leading countries were United States, followed by Switzerland. The University of Zurich was the most productive institution with 8 articles. Major topics of interest in the top 100 most-cited papers were dental implants and periodontology. The most frequently occurring keywords were systematic review, dental implants and meta-analyses. Conclusions: Systematic reviews published in high impact factor Dental journals focused on implantology and periodontology had the highest citation rates. Obviously, the top cited list is dynamic, as scientific interests and research tendencies evolve over the years.

Keywords: Bibliometrics; citation analysis; meta-analysis; systematic review.

• Bibliometrics
• Dental Implants*
• Journal Impact Factor
• Meta-Analysis as Topic*
• Periodicals as Topic*
• Periodontics
• Systematic Reviews as Topic*
• United States
• Universities
• Dental Implants

• Open Access
• Published: 29 October 2014

Patients' expectations from dental implants: a systematic review of the literature

• Jie Yao 1 ,
• Hua Tang 1 , 2 ,
• Xiao-Li Gao 1 ,
• Colman McGrath 1 &
• Nikos Mattheos 1  

Health and Quality of Life Outcomes volume  12 , Article number:  153 ( 2014 ) Cite this article

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To examine the current literature on the impact of patients' expectations on treatment outcomes or final patient satisfaction and to identify the theoretical frameworks, study designs and measurement instruments which have been employed to assess patients' expectations within implant dentistry.

A structured literature search of four databases Pubmed, Cochrane, Web of Science and PsychINFO was conducted following PRISMA guidelines. Any type of literature published in English discussing the topic of `patients expectations’ in oral health were identified and further screened. Studies reporting on expectations regarding dental implants were selected and a narrative review was conducted.

The initial search yielded 16707 studies, out of which 1051 `potentially effective studies’ were further assessed and final 41 `effective studies’ were included [Kappa = 0.76]. Ten observational studies, published from 1999 to 2013, dealt specifically with expectations of dental implants. There was a large degree of heterogeneity among studies in terms of assessment instruments. Expectations relating to aesthetics and function were primarily considered. Among the 10 studies, 8 were classified as quantitative research and 2 as qualitative research. The STROBE quality of reporting scores of the studies ranged from 13.5 to 18.0. Three of the 8 quantitative studies employed a before/after study design (prospective studies) and used visual analogue scales (VAS) to measure patient expectations.

Conclusions

There is a growing interest in patients' expectations of dental implants. Most studies are cross sectional in nature and the quality of reporting varies considerably. Expectations with respect to aesthetics and function are key attributes considered. The use of visual analogue scales (VAS) provides quantitative assessments of patients' expectations but the lack of standardization of measures prohibits meta- analyses.

Introduction

Quality assurance of health care delivery has emphasized in the importance of patient's perceptions of medical interventions and treatments since 1970s [ 1 ]. The view that patient expectations from a treatment play a potential role to their final satisfaction from the treatment outcomes has intrigued clinicians and researchers [ 2 ]. This is even more critical today, as the current practice of Evidence Based Medicine requires that the patients are actively engaged in the decision making with regards to their treatment. In addition, understanding and measuring the expectations of patients prior to treatment appears to be an essential prerequisite to achieve successful patient reported clinical outcomes.

Broadly speaking, expectations are beliefs about future consequences, which may contribute to an individual's psychological and physiological change [ 3 ]. In medicine, the variety appears in the concept, type and usage as well. According to the literature review published in 2012 by Ann Bowling and coworkers [ 4 ], the current literature failed to address the multidimensionality of this concept. Moreover, the measurement instruments used to assess expectations are very diverse, without validity and reliability test. Thus, there is a strong need to further develop the concepts of patient expectation and investigate both theoretically and empirically its implications for patient reported treatment outcomes. This need is even more pronounced with regards to treatments with dental implants, where expensive therapy is proposed for the rehabilitation of function and esthetics of patients with missing teeth. Satisfaction after treatment with dental implants appears to be evident in a number of studies. According to a prospective cohort study of patients' satisfaction following implant therapy in 10 years, more than 90% of the patients were completely satisfied with implant therapy [ 5 ]. Nonetheless, as one of the relatively new technics in dentistry, implants are still unknown to a wide segment of the population. Saha and coworkers conducted a survey in 2013 among 483 subjects to assess the awareness regarding implants and the authors indicated that more than half of the participants had no information of implants [ 6 ]. This conclusion is consistent with other studies published in recent years [ 7 ]-[ 9 ]. The lack of reliable information may be one reason leading to the development of patients' unrealistic expectations. Another possible resource for unrealistic expectations is the perceived "novelty" of this treatment, especially when coupled with the high cost of the implant therapy. Based on the view that patients' unmet expectations would negatively influence their satisfaction with the treatment outcome, identifying patients' expectations before the treatment is a necessary step to prevent patient disappointment with the final treatment outcomes.

A systematic review of the literature was conducted aiming to review available evidence with regards to patients' expectations from clinical treatments within comprehensive oral healthcare. The aim of this paper is to report the literature review outcomes within the discipline of implant dentistry. In particular, this study aims to review the evidence with regards to:

impact of patients' expectations on treatment outcomes or final patient satisfaction with treatment outcomes within implant dentistry

theoretical frameworks, study designs and measurement instruments which have been employed to assess patients' expectations within implant dentistry.

Study protocol and eligibility criteria

A wider "umbrella" search protocol was developed in order to identify evidence on the impact of patients expectations in outcomes of oral healthcare. Two independent researchers conducted the search. Studies were initially included if they met the following criteria:

Human subjects were investigated with regards to their expectations from dental treatment.

Experimental studies (randomized or not, prospective, retrospective and cross sectional) with qualitative and/or quantitative analysis.

Search strategy and data resources

Since patient "expectations" represent a rather new area in dental research, no suitable MeSH term was available. A search was broadly employed to identify as many relevant studies as possible. The overall search strategy was defined for comprehensive oral health, thus used the text words "expectation" and MeSH terms "knowledge", "attitude", "oral", "dental", "dentistry". All papers found reporting within oral healthcare were further organized in dental disciplines. The studies reporting on dental implants were selected for further analysis in this paper. An additional specific search was conducted with the keyword "expectation" and the MeSH term "dental implants", which however didn't add any further papers (Table 1 ).

Literature search results originated from the online databases: Pubmed, Cochrane, Web of Science and PsychINFO. No starting point was set in time and the final search was run on 19 September 2014. Any type of literature with the patients' expectation topic in oral health was included to the initialy screened and the hand search extended to the references listed in the included studies [Figure 1 ].

Phases in the development of eligible literatures.

Study screening and data extraction

Two reviewers (JY and HT) screened the title and abstract of each citation independently to determine whether the study would be further retrieved in full text. Based on the pre-determined eligibility criteria, studies with a clear description of the aim, method (e.g. sample type and size, study design) and result were considered. Full-text of the possible eligible studies were retrieved. After the assessment of the full text, decision was made by the two reviewers for final selection. The inter-reviewer agreement for each eligibility citation was calculated as described by Cohen J. [ 10 ]. Disagreements were resolved by discussion in the series of stages. In case of disagreement, other co-authors were involved in discussion until consensus was reached.

Once the satuies were selected for final analysis, the following data of each study was extracted by one reviewer (JY): author, year of publication, name of journal, subjects (age, diagnosis, and previous prosthodontic experiences), study design, measurements (instrument, questionnaire items and interview topic) and results. The second reviewer (HT) controlled the extracted data and if any objection or disagreement occurred, this was resolved by consensus. Meta-analysis of the results was not possible due to the wide range of study designs and sample types. Thus a narrative synthesis was undertaken.

Analysis and quality assessment

The criteria in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were utilised to evaluate the study quality [ 11 ]. The STROBE statements represent the quality standards of observational studies (cohort, case-control and cross-sectional studies). The 22 items in STROBE provided guidance to assess the title, abstract, introduction, methods, results and discussion sections. Two investigators rated the score for each study (fully met = 1; Partial met = 0.5; N/A or Not at all = 0). The mean scores of two raters were recorded as the final quality score.

Study selection

The search of four databases (Pubmed, Cochrane library, Web of Science and PsycINFO) initially provided a total of 16.707 citations. The earliest paper was published in 1966 and was available in Pubmed. After adjusting for duplicates (539 studies), language (1058 studies) and subjects (823 studies), 13.236 studies were further excluded because of no relevance to oral health. Of the remaining 1051 articles, the second round screening discarded 912 studies through evaluating the abstracts. Studies were excluded because of:

Not investigating an expectation/anticipation/request/need in the study aims (874 studies)

Investigating response expectations to the treatment like fear or anxiety (4 studies) Response expectations are investigated in systematic desensitization therapy and they are anticipations of automatic reactions to particular situational cues [ 12 ].

Investigating response expectations to HIV or other infectious disease in dental treatment (9 studies)

The study sample having dental background or special diseases other than involving dental problems (23 studies)

The full texts of remaining 76 studies were examined in detail. Forty-three studies were excluded during the final round screening because of insufficient research approach to the investigation of expectations. For example, some papers mainly investigated "self-efficacy" which we think is only a sub-determiner of expectations [ 13 ]. In addition, 8 studies were chosen from references by hand search [ 14 ]-[ 21 ]. Thus, a total of 41 studies investigating patients' expectations in oral health were identified in the final analysis. The eligibility criteria were consistent during all the stages of screening and the mean kappa value for the agreement between the reviewers was 0.76. Of these 41 studies, 10 studies (12 papers) published from 1999 to 2013 were identified to measure expectations of dental implants and were thus further analyzed for the purpose of this paper. In addition, the specific search strategy "expectation" combined with "dental implants" did not offer any new eligible papers.

Study characteristics

Out of the 10 implant related studies (12 papers), 8 were quantitative research (10 papers) and 2 were qualitative research (2 papers). The sample size ranged from 9 to 1000 subjects. The age range was not clear because some papers just provided the mean age. The study countries were UK for two studies, Austria for three studies, Brazil for two studies, Sweden, Canada and Germany for one study, respectively. Implant treatment included implants supported single crowns, fixed partial dentures and over-dentures (Table 2 ). All 10 studies (12 papers) were observational studies with the STROBE score ranging from 13.5 to 18 (total score = 22). Based on the content in STROBE , the highest score ( ≧ 9) are rated for the title, abstract, introduction (background and objectives), study design, outcome data and discussion (key results, interpretation, generalizability). The lowest score ( ≦ 2.5) are rated for bias description, study size explanation, and limitation discussion.

Quantitative studies

Three of the 8 quantitative studies utilized a before/after study design with the use of visual analogue scales (VAS) to measure the expectation pre-treatment and the actual satisfaction [ 23 ],[ 24 ] or evaluation [ 22 ] post-treatment. For example, all three studies asked patients to rate their expectations of the functional and esthetic change brought by dental implants. The items related to function were constructed either as a general idea [ 22 ],[ 23 ] or specific regarding to mastication, phonetic, comfort use and retention issues [ 24 ]. Among the three, one study claimed that post-treatment satisfaction ratings significantly exceeded expectations [ 22 ]. However, another study reported satisfaction lower than pre-treatment, expectations, especially for esthetics in patients who received implant supported fixed partial dentures [ 24 ]. All three papers considered gender, age and placement area as the variables influencing the expectation rating. Baracat and coworkers found negative correlations between age and functional expectations [ 22 ]. Heydecke and coworkers concluded high expectations of IOD (two implants supported over-denture) treatment were predictive of higher resultant evaluation only in the middle age group (35-65 years old) [ 23 ].

In conclusion, seven cross-sectional studies reported in 9 papers employed survey or rating scales (including papers using VAS). Most of studies aimed to assess patients' knowledge, awareness, expectation, information level and acceptance to dental implant. The sample varied from general population without treatment need [ 8 ],[ 9 ],[ 27 ], patients who were seeking implants [ 25 ] and patients who had completed implant treatment [ 30 ],[ 31 ].

Qualitative studies

Two qualitative studies interviewed subjects who had completed implant treatment [ 30 ],[ 31 ]. Grey and coworkers revealed participants expected to a "normalization" of their oral-health related quality of life from implant treatments, however, this "normalization" idea was abstract and individual [ 30 ]. Both two studies found patients affirmed the improvements brought by implants in their physiological, social and psychological related quality of life [ 30 ],[ 31 ].

Reported parametres

The parameters investigated in the different questionnaires were very diverse among studies (Table 3 ). The most frequently used questions were about survival time (5 studies), cost (5 studies), special oral hygiene maintenance (4 studies), information sources (3 studies) and outcome improvements like functional and aesthetical changes (4 studies). For the longevity of dental implants, Hof and coworkers [ 25 ] found that 59% of the subjects believed implants could last for a lifetime. However, the same result in Pommers' [ 8 ] was 24% and Teppers' [ 27 ] 34%. Seven percent of the participants in Rustemeryer's study believed implants could last longer than 25 years [ 9 ]. Most current studies pointed out that patients believed the cost of implant treatment to be high. The treatment cost related to income was one of the determinants to hinder subjects from making treatment decisions [ 9 ],[ 25 ],[ 26 ],[ 28 ],[ 31 ]. Three studies assessed the information sources of patients with regards to dental implants and showed the majority of the patients to be informed from the dentist, however to a varying extend of 68% [ 27 ], 41% [ 9 ] and 74% [ 8 ] respectively. Another common question was whether implants need special care. The answers were similar among studies. Less than 6% participants thought dental implant need less oral hygiene care than natural teeth [ 8 ]. The data in Rustemeyer's study was 7% [ 9 ] and Tepper's was 4% [ 27 ]. Four studies discussed treatment outcomes (included 2 qualitative studies). Allen and coworkers applied ordinal scale to prove subjects expected dramatic improvement in stability, retention and comfort of implant-retained prosthesis, especially for mandibular (Mean media score = 2.0, very satisfied) [ 29 ]. Rustemeyer stated most patients regarded the functional and aesthetics improvements as something important and the percentage of women who judged aesthetical change as vital was significant higher compared with men (68% and 41% respectively, P < 0.05) [ 9 ]. In addition, four studies pointed out the unrealistic expectations of implant in patients' mind [ 8 ],[ 9 ],[ 23 ],[ 29 ]. Hof and coworkers still investigated issues related to bone graft in implant surgery and the results showed patients preferred the minimal invasive treatment alternatives [ 25 ].

To our knowledge, this is the first systematic review on patients' expectations of dental implants. The area of implant dentistry is a relatively new modality in oral healthcare, which involves rehabilitation treatments with often significant costs. It is also a treatment modality which the patients have little experience and understanding of prior to becoming recipients of implants. Information about implants is widely available through Internet and social media, but with limited quality assurance and often misleading or inappropriate content. As communication bias, uncertainties of diagnosis and therapy often lead to misunderstandings, all unmet expectations may cause future dissatisfactions. For these reasons Implant dentistry was singled out as the focus of this review.

Ten studies reported in 12 papers are characterized by various study designs and sample types. The vague concepts of expectation and the non-standard instruments used among studies provide weak evidence for clinical reference. This prevented any attempt to conduct a meta-analysis. Therefore, the focus of this study is to narratively synthesise the conclusions, as well as evaluate the methodological characteristics of the available studies.

Main outcomes and evaluation

Expectations of improvements resulting from treatment are the main focus of 10 studies. Seven of these studies [ 9 ],[ 22 ]-[ 24 ],[ 29 ]-[ 31 ] measured the outcome expectations with simple questions like "Do you expect implants improve the functional and esthetic conditions?" Two studies measured the general functional change after the treatment [ 22 ],[ 23 ]. In another study, instead of specific measurement, patients were asked with regards to chewing ability, phonetic feeling, etc. [ 24 ]. Two papers used visual analogue scales (VAS) in measuring pre-treatment expectations and post-treatment satisfactions from the outcomes [ 23 ],[ 24 ]. Interestingly, the results were not always positive. Specific items like mastication, phonetic, comfort use and retention issues showed lower satisfaction after treatment [ 24 ] than the pre treatment expectations. One of the reasons may be that patients with more detailed considerations of functional experiences may be more sensitive to the change in oral conditions.

The high cost of implants is emphasised in most studies. Patients are reported to often complain about the high cost and many believe this will prohibit them from receiving implant therapy. High cost may also be one of reasons contributing to unrealistic expectations. In our review, 4 papers [ 8 ],[ 9 ],[ 23 ],[ 29 ] with big sample size found unrealistic expectations often existed among patients. Although the dentists largely remains the main information resource with regards to implants at present [ 8 ],[ 9 ],[ 27 ], the reliance of patients is diverse, varying from 41 to 74%.

All studies analyses were observational in terms of design. The definitions and concepts of expectations were simple and one-fold without deeper exploration. Studies seldom discussed the definition of expectations and miss-interchangeable concepts were identified. For example, a lot of studies used the terms "expectations" as synonyms to "need", "perspectives", or "requests", etc. [ 8 ],[ 25 ],[ 27 ],[ 31 ]. Actually, these are possibly similar sounding terms in everyday language, but are very diverse when used in scientific terminology within Psychology. The ambiguous definitions can confuse readers when encountering different concept models without well-integrated interpretations. These issues also constitute a major difficulty when scientifically investigating the expectations related topics.

Due to the diversity of definitions (or absence of them) for expectations, the studies included in this review utilised different methodologies and sample types, which also increased the risks of bias. Not surprisingly, the studies identified in this review are weak in bias interpretation. Two qualitative studies investigated expectations of patients who had completed implant treatment [ 30 ],[ 31 ]. These retrospective analyses offer an improved understanding of expectations, as related to simple one-off studies. The relatively longer study period, extending to before and after treatment may guide investigators to gain more detailed insights into patients' mind. The other sample types consist of patients who are seeking implants [ 25 ] and general population without treatment need [ 8 ],[ 9 ],[ 27 ]. The differences in treatment need may significantly affect the passive or active thinking and patients' expectations.

Outcome expectations are emphasised. However, as the instruments employed in studies are not always optimal, research results cannot be understood within a consequent context. Research in expectations within the discipline areas related to orthodontics [ 32 ] and periodontics [ 15 ],[ 16 ] appear to have instruments with good validity and reliability. The expectations concepts are explored deeper and multidimensional as well. This might be due to the fact that implant therapy is relatively new, when compared with the two other well-established disciplines.

A large body of literature in this review discusses the association between expectations and satisfaction, which is also a hot topic in other fields related to patient-reported outcomes (PROs ) [ 33 ],[ 34 ]. In contrast to expectations, which are relatively new concept, patient satisfaction has been investigated longer and in more depth. From the systematic review by Crow [ 2 ], a census that expectations could predict satisfaction cannot be reached. However, many researchers believe the potential influence of patient expectations and the change of expectations may significantly impact the final satisfaction with a treatment [ 3 ],[ 12 ]. This should be further investigated in future experimental study.

Limitations and future directions

Any attempt to review evidence in the field of "expectations" in oral healthcare is limited by the lack of a standardized terminology and widely accepted definitions. Consequently, it was a strategic decision of the authors to adopt a "sensitive" rather than a specific search strategy in order to assess as many potentially relevant papers as possible. For this reason, keywords such as "knowledge" and "attitudes" were also included in the search, although not expected directly relevant to the focus area. As it was shown, some papers included relevant data, although they would have not been found by more specific search. For example, Pommer and Teppers' research on access of patients' information to dental implant [ 8 ],[ 27 ], also report findings on patients' expectations. The search strategy this way also provided papers within other dental disciplines, which although are not the focus of this paper, might be reviewed in future studies.

The search of literature is restricted to English-language publications. The search strategy was broad with the aim to find as many relevant studies as possible. Nonetheless, the search process was only limited to electronic databases. Due to the ambiguity in the definitions of expectations and related concepts selection bias is not unlikely, although effort has been taken to minimize it through the methodology and the utilisation of two reviewers. With the heterogeneity in study designs and sample types, the results were extracted with an inevitable degree of subjectivity. Implant Dentistry as evolved tremendously in the last two decades and one can expect that patients attitudes and expectations have also evolved in time. However as one of the aims of this study was to also assess theoretical frameworks and instruments used, it was decided to not set a starting time point for the search. In reality this proved to be not significant, as the few publications available are clustered mainly in the decade 2000-2010.

Expectations should be considered multidimensional and malleable during different clinical stages. Questions using generic ideas/ definitions of expectations may lead to deviation from specific concepts. The patient expectations should be better studied within corresponding scenarios. For example, patients' expectations from treatments in public hospitals may be significantly different when compared with private clinics. Researchers could better address this when considering of the specific situations the patients may encounter, what kind of expectations they may form and how this would be influenced by sub-determinants such as previous experiences, personal characteristics, social and psychological factors.

In sum, there is a need for future studies designed to:

Produce a specific and theoretically sound definition of patients' expectations from implant treatments, which addresses the complex nature of the phenomenon.

Construct the theoretical model of how patients form expectations from dental implant treatment and demonstrate its determinants and contributing factors both theoretically and experimentally.

Classify the changes or different roles of expectations at different clinical stages, through a longitudinal study design.

Build standardized instruments to help objectively assess patient expectations and better understand how these expectations are formed and developed.

Clarify the impact of expectations to the final satisfaction with treatment outcome

Expectations from dental implants have been investigated in a diversity of approaches within the available literature. The biggest part concerns outcome expectations of improvements in functional and esthetic aspects of treatment. The current findings of research are limited by weak study design and non-standardized instruments which decrease the level of evidence. Unrealistic expectations are often found among patients, which may lead to dissatisfaction with final outcomes. The concept of expectations should be further developed theoretically and experimentally. In addition, relation between expectation and satisfaction should be investigated in future research.

Authors' contributions

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• Published: 10 February 2017

Literature reviews: Patient-centred care

• C. A. Yeung 1  

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Sir, I read with interest the article by Scambler et al . regarding patient-centred care in dentistry. 1 There seems to be considerable delay of this article being prepared and accepted for publication in August 2016, as the literature review was searched up to May 2012. The conclusion drawn from this systematic review may no longer be valid.

The General Dental Council launched Standards for the dental team on 30 September 2013. It replaces Standards for dental professionals and its supplementary guidance booklets (eg Principles of patient consent ) published in 2005. To support the implementation of the new Standards for the dental team , the General Dental Council has also developed an interactive site with case studies, scenarios and frequently asked questions. 2 The authors have made no attempt to mention this important update in the Introduction section of their paper. 1 As this article 1 is not the first systematic review on patient-centred care in dentistry, you will usually expect the authors of this article to provide an updated search of the literature and comment on any previous systematic review on this topic. I am surprised that the authors had made no attempt to mention a previous systematic review by Mills et al . in 2014. 3 There are also a number of errors associated with this article. 1 The old name of NICE was used in reference 4 . In 2005, the name of NICE was changed from the National Institute for Clinical Excellence to the National Institute for Health and Clinical Excellence. Following the Health and Social Act 2012, NICE was renamed the National Institute for Health and Care Excellence in 2013. In addition, superscripts have not been used in Tables 1 and 2 to link the included articles to the reference list at the end of the article. 1 This causes some difficulties in locating the included articles.

Readers will be interested to read the latest guidance on when and how to update systematic reviews. 5 A checklist can be found in Appendix 3 of the supplementary material on the web. 6

Scambler S, Delgado M, Asimakopoulou K . Defining patient-centred care in dentistry? A systematic review of the dental literature. Br Dent J 2016; 221 : 477–484.

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Mills I, Frost J, Cooper C, Moles D R, Kay E . Patient-centred care in general dental practice – a systematic review of the literature. BMC Oral Health 2014; 14 : 64.

National Institute for Health and Care Excellence (NICE). NICE: Who we are. Online information available at https://www.nice.org.uk/about/who-we-are (accessed 10 November 2016).

Garner P, Hopewell S, Chandler J et al. When and how to update systematic reviews: consensus and checklist. BMJ 2016; 354 : i3507.

Garner P, Hopewell S, Chandler J et al. Appendix 3. PUGS Checklist for updating a systematic review: deciding when and how. Online information available at http://www.bmj.com/content/bmj/suppl/2016/07/20/bmj.i3507.DC1/garp030756.ww_default.pdf (accessed 10 November 2016).

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Dental insurance: A systematic review

Bharath kumar garla.

Department of Public Health Dentistry, Vyas Dental College, Jodhpur, Rajasthan, India

1 Department of Conservative Dentistry and Endodontics, Darshan Dental College and Hospital, Udaipur, Rajasthan, India

K. T. Divya

2 Department of Conservative Dentistry and Endodontics, Government Dental College and Research Institute, Vijayanagar Institute of Medical Sciences, Karnataka, India

To review uses of finance in dentistry. A search of 25 electronic databases and World Wide Web was conducted. Relevant journals were hand searched and further information was requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity. Insurance has come of ages and has become the mainstay of payment in many developed countries. So much so that all the alternative forms of payment which originated as an alternative to fee for service now depend on insurance at one point or the other. Fee for service is still the major form of payment in many developing countries including India. It is preferred in many instances since the payment is made immediately.

INTRODUCTION

Health has been declared as fundamental human right. Oral health is an integral part of general health and, therefore, can be rightly called as the gateway of the body. The prohibitive cost of dentistry has been the main hindrance which deprives people of availing the services.[ 1 ]

The increased cost of health care is due to the public's increasing demand for health services, ever growing technology of health care, lack of incentives in health care, higher quality of health care, and general inflation. As marked increase in the expenditure of public funds for healthcare services in all industrialized countries occurred, new methods of providing services evolved.[ 1 ]

In developing countries like India, fee for service is still the major type of payment mechanism. Very few people can afford to utilize this service regularly. Most of the people will visit dentists only for curative services occasionally. Preventive measures are not given much importance due to high cost, and hence, the percentage of population availing dental services has remained low. An attempt has been made here to review various types of payment mechanisms existing in different countries.

Fee for service was the first mode of payment to the dentist with respect to the services received. It co-existed with dentistry and was the main type of payment for many years until the other forms of payment came into existence.[ 1 ]

1945- Start of voluntary prepaid comprehensive dental care in St. Louis, USA

1948- Establishment in England of a National Insurance Scheme including Comprehensive Dental Service

1948- Bisell B. Palmer of New York City founded group health dental insurance as open-panel pre-payment system.

1949- Group Health Association, a consumer cooperative in Washington, established a clinic dental service, which soon changed from fee-for-service basis to prepayment.

1954- Washington State Dental Council organized Washington State Dental Services Corporation for helping administer prepayment dental care plan for children of International Longshoreman's Union Pacific Maritime Association. This mechanism was soon found to be the best form of rendering dental care.

1966- Medicare brought medical care to the aged of the US without regard to the income. This did not include dentistry, but Medicaid did.

1973- Health Maintenance Organization Act was passed which provided government support for organizations providing standardized comprehensive care to the individuals in enrolled groups.

1989- Delta Dental Plan and other agencies were covering about 107 million beneficiaries.

However, fee for service continues to be the major mechanism of payment in many developing countries.[ 2 ]

MATERIALS AND METHODS

All epidemiological studies (cross-sectional, case-control, cohort and clinical trials) involving health insurance, dental faineance, oral health care delivery system were considered eligible for the present review.

Study selection was conducted in two phases: (1) Abstracts and titles were selected and (2) full texts of the selected titles were obtained and read to determine the final sample set. Only studies published in English language were considered due to the virtual absence of research published in other languages as resulted from preliminary electronic database searches.

The choice of key words was intended to be broad to collect as much relevant data as possible without relying on electronic means alone to refine the search results. The titles of the articles retrieved were searched manually or electronically. After that, electronic search of the abstracts and full texts was performed to identify relevant articles. Also, the references of each article were thoroughly inspected for more possible candidates. The resulting articles were then subjected to clear inclusion and exclusion criteria by two reviewers.

Literature search

The electronic search was carried out in PubMed, Cochrane Library and google scholar databases, and papers dated between December 1951 and December 2012 were selected. Based on the aim of the present systematic review, in the following Table 1 search descriptors were used together.

Search strategy

Selection of studies and data extraction

Studies retrieved from the databases were selected after reading the abstracts and titles, following a calibration exercise with 10% of the studies read by reviewers to determine interexaminer agre ement (Kappa: 0.68 to 0.97). Disagreements were resolved by consensus. Reviews were included, and their reference lists were searched in turn for any studies not retrieved by the electronic search. However, this process yielded no further studies.

Information sources and search

The following electronic databases were searched: Medline, Embase ® , The Cochrane Library and Google Scholar ® . Two preliminary searches were conducted in June 2011 to obtain an overall idea of findings and to polish searching terms (MeSH words) and limits. No topic related nor relevant finding resulted from both The Cochrane Library and Google Scholar ® ; these electronic databases were therefore excluded from final Boolean search. Final search was conducted on January 30th, 2013. Reference lists of included and relevant papers were reviewed. Abstract was collected for all findings.

Eligibility criteria

Protocol for this review was the PRISMA 2009 checklist (available at www.prisma-statement.org ).

Included studies

• Clearly described objective, methods and results, with no significant discrepancies
• Case reports, case series, outbreak investigations and abstracts were excluded
• The study design was a cohort, cross-sectional, case-control
• Articles were reviewed for relevance
• Inter-rater reliability of relevancy ratings was determined since more than one reviewer was used
• Study design (included: cohort, cross-sectional, case-control)
• Data collection method and method of handling the data. (included variables, e.g., description of tools, pretesting of tools, use of self-report, assessment/screening tools pretested for validity, reliability).

Investigator screened all collected findings and registered title, author and whole reference in two Excel files (one for included and one for excluded findings, according to eligibility criteria) using a screening guide created on eligibility criteria. Kind of source was registered as reason for exclusion. Duplicates from different electronic databases were excluded. The full text of all studies judged potentially eligible in at least one screening were retrieved. Then, investigator screened the full text for inclusion using a screening guide and all findings.

Evaluation of scientific articles

The articles relevant for study which met the inclusion criteria were rated as strong (0), moderate (3), weak (9), and very weak (16). Validity scores indicated whether a study met the reviewer's criteria for research rigor.

A total of 766 potentially relevant records were found in the seven databases, 56 of which were duplicated. Thus, the abstracts of 587 studies were read. A total of 400 references were excluded based on the abstracts, and 65 were selected for full-text analysis, 14 of which were selected for inclusion. No clinical trials were found by the searches, although all caution was taken to try to find them. For this reason, no clinical trials are considered in this review.

One study was on social insurance for dental care in Iran. Results reported around 90% of Iranians are covered for health insurance within a Bismarckian system to which the employed, the employers, and the government contribute.[ 3 ]

Commercial insurance companies

The year 1929 is generally credited as marking the birth of modern health insurance. It was in this year that Justin Ford Kimball established a hospital insurance program at the Baylor University Hospital for the school teachers of Dallas, Texas. The program was an immediate success and the concept of health insurance spread to other parts as well.[ 4 ]

Insurance principles and dental care

During the years after World War-II, when medical insurance was growing rapidly, dental care was one of the “fearful” four areas of health care (dental care, psychiatric care, prescription drugs, and long-term care) considered uninsurable by carriers.[ 5 ] This reasoning was based on the assumption that the very nature of dental need violated the basic principles of insurance.

Since 1948, UK has a state-financed public oral healthcare system within the National Health Service (NHS). Nearly 85% of the UK dentists work within the General Dental Services (GDS). Vast majority treat patients both within the NHS and part privately. All oral health care within the NHS is free for under 18 years, students under 19 years, pregnant mothers, unemployed, low-income persons, and inpatients in hospitals. Other NHS patients pay 80% of their fees up to EUR 500; above this figure they pay nothing. In 2001, dentists received payment from the NHS through a combination of capitation and fees for item of treatment for patients aged 0–17 years. Capitation covers prevention, simple fillings, and extractions. Crowns, dentures, and orthodontics are paid for on a fee item basis. Twenty-four percent of adult patients receive some or all of their dental treatment under private arrangements.[ 6 ]

Almost 7 million people or 16% of the total population of South Africa are covered by third-party insurance and make use of the private sector for their health services. The remaining 84% or 38 million people are dependent on the state for their health services.[ 7 ]

Dentistry in India has been growing at a rapid pace and, in fact, has taken the lead, as from a mere three dental colleges in 1947, now after 50 years, there are more than 200 dental institutes all over India and almost 12,000 people with BDS degree. Many oral health surveys have been done, and the prevalence rates of various oral diseases in the population are dental caries (40–45%), periodontal diseases (advanced disease in 40%), malocclusion (30% of children), oral cancer (12.6 per lakh population), dental fluorosis endemic in 230 districts of 19 states, and edentulousness (tooth loss) in 19–32% of elderly population above 65 years.[ 8 ]

There is no reliable data on the oral health situation in India. Sporadic studies suggest a rising level of dental diseases in India. Since gaining independence in 1947, health system has evolved over the years. It is clear that India is an overpopulated country with a large percentage of the population below the poverty line. As per dental manpower committee report of the Dental Council of India, there are approximately 44,000 dentists for a population more than 100 million, with a dentist population ratio of 1:30,000 in urban areas and 1:150,000 in rural areas. It has been well established that preventive programs are very cost-effective and advantageous for fighting oral diseases.

Non-profit health service corporations

The history of the dental service corporation movement began in 1954, when representatives of the health and welfare fund jointly administered by the International Longshoremen and Warehousemen's Union and the Pacific Maritime Association approached the organized dental profession on the West coast to see about instituting an experimental dental care program for the children of the union members. As a result of subsequent discussions that year, the Washington State Dental Association sponsored the formation of the first not-for-profit dental service corporation which was called Washington State Dental Service. As of 1969, there were 27 active dental service plans in the United States providing prepaid dental care coverage to approximately 2 million Americans.

Reimbursement of dentists in Delta Dental Plans

Delta Dental Plans at first used the Usual, Customary and Reasonable (UCR) fee-for-service concept almost exclusively, and this method of payment still dominates. Under the fee-for-service programs, the way in which a dentist is reimbursed depends on whether the dentist is participating or non-participating (often referred to as “par” and “no-par” dentists) with Delta. A participating dentist is one who has entered into a contractual agreement to provide care to eligible persons. Non-participating dentists can also treat patients covered under Delta Dental Plans and be reimbursed by Delta. They do not need to prefile their fees and are not subject to fee audits or withholding. However, non-participating dentists are usually paid at the 50 th percentile of fees, rather than at the 90 th percentile.[ 9 ]

Health maintenance organizations (HMO'S)

The first prototype health maintenance organization (HMO) was developed in the Elk city, Oklahoma, in the early 1920s. In the latter 1930s, the development of the Kaiser system began. The Kaiser development started essentially as a method to provide healthcare services to workers (building the Grand Coulee Dam which did not have access to medical care). Kaiser was the largest of the HMOs in the nation at that time and served 13 states with a total enrollment close to 5 million.[ 10 , 11 ]

Medicare was brought into being because the voluntary health insurance system was unable to provide adequately for people over age 65 since the income of persons aged 65 and older is usually considerably less than those in the employed population and, therefore, have limited funds to spend on health care.[ 12 ]

Creation of Medicaid and Medicare by enactment of the Social Security Amendments of 1965 established a major role for the Federal Government in financing health care. Medicaid title XIX is a federally assisted state program which offers health benefits to low-income persons on public assistance and, in some states, to those deemed medically needy because their incomes are only slightly above the welfare standards. Depending upon the per capita income of a state's population, the federal government pays between 50 and 78% of the costs of the state's Medicaid program.

The most serious defect of the studies was the lack of appropriate design and analysis. Many studies did not present an analysis at all. There are limited numbers of studies on dental financing system, so it was difficult to correlate different studies.

The use of dental care is low relative to the existing need mainly because of the cost of services rendered. Dental prepayment programs are, therefore, considered an effective mechanism for extending dental services to more people. Third-party payment for dental services is, therefore, payment to the dentist by an agency rather than directly by the patient. The third party is sometimes called the carrier, insurer, underwriter, or administrative agent. Usually, however, the term third party, without further qualification, refers to a private carrier such as an insurance company; when the government acts as a third party, the term most commonly used is public financing of care.

A study done on social insurance for dental care in Iran[ 3 ] concluded that the dental sector of Iranian social insurance should establish a strategic purchasing plan for dental care with the aim of improving performance and access to care. Around 90% of Iranians are covered for health insurance within a Bismarckian system to which the employed, the employers, and the government contribute. The system has developed piecemeal over the years and is characterized by a complexity of revenue collection schemes, fragmented insurance pools, and passive purchasing of dental services.

Another study conducted in South Africa[ 13 ] concluded that South Africa compares unfavorably with middle-income countries on the ratios of medical and dental professionals; many districts have limited access to specialists and subspecialists. The unacceptable ratio of doctors, dentists, and other health professionals per capita needs to be remedied, given South Africa's impressive reputation for its output of health professionals, including the areas of medical training, clinical practice, and clinical research. The existing output from South Africa's eight medical schools of MB ChB and specialist graduates is not being absorbed into the public health system, and neither are other health professionals.

Oral health care is mainly financed by government-regulated or compulsory social insurance in seven countries, viz. Austria, Belgium, France, Germany, Luxembourg, The Netherlands, and Switzerland.[ 14 ] Providing universal or near-universal coverage by membership of insurance institutions, these systems provide oral health care for about 180 million people across Europe and to almost half of all EU citizens. In the Nordic countries[ 15 ] and the UK, entitlement to care is typically based upon residence or citizenship, and apart from in Norway and Iceland it is provided within a tax-funded and government-organized health service. In southern Europe, Norway, Ireland, and Iceland, oral health care is largely financed directly by the patient, with occasional support through private insurance. Some publicly funded and organized services do exist in these countries, but generally only for specific population groups (e.g. children, unemployed) or in particular regions.

• It has been stated earlier that fee for service was the first form of payment that existed from the beginning
• However, due to the problems faced by the patients in coughing up the cost of the treatment at a single shot, other forms of payment which intended to give a breathing space for the patients came into existence
• Different forms of payment have their own set of rules and regulations which the member (patient) had to strictly adhere to, if he was to receive the benefits of the program. Therefore, the freedom was entirely the patient's to understand and enroll in a program which he thought was beneficial for him
• Insurance has come of ages and has become the mainstay of payment in many developed countries. So much so that all the alternative forms of payment which originated as an alternative to fee for service now depend on insurance at one point or the other
• However, fee for service is still the major form of payment in many developing countries including ours. It is preferred in many instances since the payment is made immediately.

An attempt has been made here to illustrate all the available forms of payments. One could not universalize a single form of payment considering the diversifying factors that govern dentistry as well as human nature. Ultimately, it is entirely up to the dentist and his patient to work out the most suitable form of payment in which each could be happy and satisfied.

Source of Support: Nil

Conflict of Interest: None declared.