The process of providing preventive dental care: A grounded theory study of dentists’, dental teams’ and patients’ experiences.

Abstract

Background: This study was built on a previous Australian randomized controlled trial. Intervention practices in the trial were provided with evidence-based preventive protocols to guide their treatment of dental caries. During that trial, the numbers of decayed, missing and filled teeth were monitored. Outcomes in the intervention practices varied widely; this qualitative study was designed to explain how dentists, their teams and patients adopted evidence-based preventive care in practice. Methods: 40 participants (10 dentists, 2 hygienists, 9 dental assistants, 2 practice managers and 17 patients) were interviewed about their experience and work processes. Analysis involved transcript coding, detailed memo writing, and data interpretation. Results: Dentists and their teams talked about a process of slowly adapting their practices towards preventive care. Dentists spoke spontaneously about two “assumptions” or “rules” underpinning continued restorative treatment. They said that these assumptions were deeply held, and acted as a barrier to provide preventive care: 1) dentists believed that some patients were too “unreliable” to benefit from prevention; and 2) dentists believed that patients thought that only tangible restorative treatment offered “value for money”. Dentists also described other factors that could hinder prevention: in particular, having an historical restorative background and being “focused on cutting cavities fast and well”. On the positive side, successful adaptation was possible (1) when the dentist-in-charge brought the whole dental team together – including other dentists – and got everyone interested and actively participating during preventive activities; (2) when the physical environment of the practice was re-organized around preventive activities, (3) when the dental team was able to devise new and efficient routines to accommodate preventive activities, and (4) when the fee schedule was amended to cover the delivery of preventive services, which hitherto was considered as “unproductive time”. Whether or not they were able to adapt, all dentists trusted the concrete clinical evidence that they had produced themselves, that is, seeing results in their patients mouths made them believe in a specific treatment approach. Patients talked about their experience of dental care, particularly about the relationship between patients and dentists during the provision of preventive care and advice in general dental practices. Historical, biological, financial, psychosocial and habitual dimensions of patients’ experience of dental care and self-care were revealed. Participants were amazed by their new experience of dental care without “drilling and filling” teeth and characterised dentists as either “old-school” or “new-school” based on the treatment options provided and the clinical relationship offered. Conclusion: Translating evidence into dental practice entailed a slow and complex adaptation process, requiring more than the removal of barriers. The findings suggest that dentists should be encouraged to look at preventive care as a central part of their practices, to lead their teams toward preventive care and to experience results that are self-reinforcing and offer benefits to all involved.