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Objectives: To develop outcomes of care quality measures derived from the dental electronic health record (EHR) to assess the occurrence and timely treatment of tooth decay. Methods: Quality measures were developed to assess whether decay was treated within 6 months and if new decay occurred in patients seen. Using EHR-derived data of the state of each tooth surface, algorithms compared the patient's teeth at different dates to determine if decay was treated or new decay had occurred. Manual chart reviews were conducted at three sites to validate the measures. The measures were implemented and scores were calculated for three sites over four calendar years, 2016 through 2019. Results: About 954 charts were manually reviewed for the timely treatment of tooth decay measure, with measure performance of sensitivity 97%, specificity 85%, positive predictive value (PPV) 91%, negative predictive value (NPV) 95%. About 739 charts were reviewed for new decay measure, with sensitivity 94%, specificity 99%, PPV 99%, and NPV 94%. Across all sites and years, 52.8% of patients with decay were fully treated within 6 months of diagnosis (n = 247,959). A total of 23.8% of patients experienced new decay, measured at an annual exam (n = 640,004). Conclusion: Methods were developed and validated for assessing timely treatment of decay and occurrence of new decay derived from EHR data, creating effective outcome measures. These EHR-based quality measures produce accurate and reliable results that support efforts and advancement in quality assessment, quality improvement, patient care and research.

While adverse events (AEs) are all too prevalent, their underlying causes are difficult to assess because they are often multifactorial. Standardizing the language of dental AEs is an important first step toward increasing patient safety for the dental patient.We followed a multimodal approach building a dental AE inventory, which included a literature review; review of the MAUDE database; a cross-sectional, self-administered patient survey; focus groups; interviews with providers and domain experts; and chart reviews.One hundred eight unique allergy/toxicity/foreign body response, 70 aspiration/ingestion of foreign body, 70 infection, 52 wrong site/wrong patient/wrong procedure, 23 bleeding, 48 pain, 149 hard tissue injury, 127 soft tissue injury, 91 nerve injury, 171 other systemic complication, and 177 other orofacial complication were identified. Subtype AEs within the categories revealed that allergic reaction, aspiration, pain, and wrong procedure were the most common AEs identified among known (i.e., chart reviews) and hypothetical (i.e., interviews) sources.Using a multimodal approach, a broad list of dental AEs was developed, in which the AEs were classed into 12 categories. Hard tissue injury was noted frequently during interviews and in actuality. Pain was the unexpected AE that was consistently identified with every modality used.Most AEs result in temporary harm with hard tissue injury being a common AE identified through interviews and in actuality through chart reviews. Acknowledging that AEs happen is an important step toward mitigating them and assuring quality of care for our patients.

Background Although sealants are an established and recommended caries-preventive treatment, many children still fail to receive them. In addition, research has shown that existing measures underestimate care by overlooking the sealable potential of teeth before evaluating care. To address this, the authors designed and evaluated 3 novel dental electronic health record–based clinical quality measures that evaluate sealant care only after assessing the sealable potential of teeth. Methods Measure I recorded the proportion of patients with sealable teeth who received sealants. Measure II recorded the proportion of patients who had at least 1 of their sealable teeth sealed. Measure III recorded the proportion of patients who received sealant on all of their sealable teeth. Results On average, 48.1% of 6- through 9-year-old children received 1 or more sealants compared with 32.4% of 10- through 14-year-olds (measure I). The average measure score decreased for patients who received sealants for at least 1 of their sealable teeth (measure II) (43.2% for 6- through 9-year-olds and 28.4% for 10- through 14-year-olds). Fewer children received sealants on all eligible teeth (measure III) (35.5% of 6- through 9-year-olds and 21% of 10- through 14-year-olds received sealant on all eligible teeth). Among the 48.5% who were at elevated caries risk, the sealant rates were higher across all 3 measures. Conclusions A valid and actionable practice-based sealant electronic measure that evaluates sealant treatment among the eligible population, both at the patient level and the tooth level, has been developed. Practical Implications The measure developed in this work provides practices with patient-centered and actionable sealant quality measures that aim to improve oral health outcomes.

Background Dentists strive to provide safe and effective oral healthcare. However, some patients may encounter an adverse event (AE) defined as "unnecessary harm due to dental treatment." In this research, we propose and evaluate two systems for categorizing the type and severity of AEs encountered at the dental office. Methods Several existing medical AE type and severity classification systems were reviewed and adapted for dentistry. Using data collected in previous work, two initial dental AE type and severity classification systems were developed. Eight independent reviewers performed focused chart reviews, and AEs identified were used to evaluate and modify these newly developed classifications. Results A total of 958 charts were independently reviewed. Among the reviewed charts, 118 prospective AEs were found and 101 (85.6%) were verified as AEs through a consensus process. At the end of the study, a final AE type classification comprising 12 categories, and an AE severity classification comprising 7 categories emerged. Pain and infection were the most common AE types representing 73% of the cases reviewed (56% and 17%, respectively) and 88% were found to cause temporary, moderate to severe harm to the patient. Conclusions Adverse events found during the chart review process were successfully classified using the novel dental AE type and severity classifications. Understanding the type of AEs and their severity are important steps if we are to learn from and prevent patient harm in the dental office.

Objectives: Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016. Methods: This cross-sectional study uses the Medical Office Survey on Patient Safety Culture that was modified for dentistry and administered at 4 US dental institutions during the 2016 calendar year. All dental team members were invited to complete electronic or paper-based versions of the questionnaire. Results: Among 1,615 invited participants, 656 providers responded (rate, 40.6%). Medical institutions outperformed the dental institutions on 9 of the 10 safety culture dimensions, 6 of the 6 overall quality items, and 8 of the 9 patient safety and quality issues. The surveyed dental institutions reported the strongest average percentage positive scores in organizational learning (85%) and teamwork (79%). Conclusion: These findings suggest that the patient safety culture progressed over time. However, there is still heterogeneity within safety culture among academic dental, private (nonacademic), and medical clinics. Knowledge Transfer Statement: Patient safety is the first dimension of quality improvement. Administering the Medical Office Survey on Patient Safety Culture within dental clinics represents a key measure to understand where improvements can be made with respect to patient care safety.

Process-of-care quality measure research can be used to identify gaps in the delivery of dental services to pregnant patients. The aim of this study was to evaluate the types of dental services that pregnant patients received in four dental clinics over five years as documented in the electronic health record (EHR). To accomplish this objective, the authors modified and validated a previously published claims-based dental quality measure for EHR use. After the electronic dental quality measure specifications were defined, the number of pregnant patients was calculated at three academic dental institutions and one large accountable care organization, and the types of dental care services they received over a five-year period (2013-17) were determined. Calibrated reviewers at each institution independently reviewed a sub-sample of patient charts to validate the information obtained from EHR queries, and the concordance between manual chart reviews and EHR query reports was analyzed. Of the 335,078 women aged 15-44 years who received care at the four clinics for the five reporting years, 3.9% (n=13,026) were pregnant. Among these pregnant patients, 48.9% (n=6,366) received a periodic dental examination; 30.0% (n=3,909) received a comprehensive dental exam; and 21.5% (n=2,799) received additional dental services, irrespective of comprehensive or periodic oral evaluations. Overall, the mean proportion of pregnant patients seeking care in these academic dental and group practice clinics was low, but 78.9% of them received either a periodic or comprehensive oral evaluation. Given the importance of oral health care during pregnancy, these findings suggest a need for curriculum development to incorporate prenatal oral health education in the training of dental students.

Introduction: Electronic health record (EHR) systems provide investigators with rich data from which to examine actual impacts of care delivery in real-world settings. However, confounding is a major concern when comparison groups are not randomized. Objectives: This article introduced a step-by-step strategy to construct comparable matched groups in a dental study based on the EHR of the Willamette Dental Group. This strategy was employed in preparation for a longitudinal study evaluating the impact of a standardized risk-based caries prevention and management program across patients with public versus private dental insurance in Oregon. Methods: This study constructed comparable dental patient groups through a process of 1) evaluating the need for and feasibility of matching, 2) considering different matching methods, and 3) evaluating matching quality. The matched groups were then compared for their average ratio in the number of decayed, missing, and filled tooth surfaces (DMFS + dmfs) at baseline. Results: This systematic process resulted in comparably matched groups in baseline covariates but with a clear baseline disparity in caries experience between them. The weighted average ratio in our study showed that, at baseline, publicly insured patients had 1.21-times (95% CI: 1.08 to 1.32) and 1.21-times (95% CI: 1.08 to 1.37) greater number of DMFS + dmfs and number of decayed tooth surfaces (DS + ds) than privately insured patients, respectively. Conclusion: Matching is a useful tool to create comparable groups with EHR data to resemble randomized studies, as demonstrated by our study where even with similar demographics, neighborhood and clinic characteristics, publicly insured pediatric patients had greater numbers of DMFS + dmfs and DS + ds than privately insured pediatric patients. Knowledge Transfer Statement: This article provides a systematic, step-by-step strategy for investigators to follow when matching groups in a study—in this case, a study based on electronic health record data. The results from this study will provide patients, clinicians, and policy makers with information to better understand the disparities in oral health between comparable publicly and privately insured pediatric patients who have similar values in individual, clinic, and community covariates. Such understanding will help clinicians and policy makers modify oral health care and relevant policies to improve oral health and reduce disparities between publicly and privately insured patients.

Bone level as measured by clinical attachment levels (CAL) are critical findings that determine the diagnosis of periodontal disease. Deep learning algorithms are being used to determine CAL which aid in the diagnosis of periodontal disease. However, the limited field-of-view of bitewing x-rays poses a challenge for convolutional neural networks (CNN) because out-of-view anatomy cannot be directly considered. This study presents an inpainting algorithm using generative adversarial networks (GANs) coupled with partial convolutions to predict out-of-view anatomy to enhance CAL prediction accuracy.Retrospective purposive sampling of cases with healthy periodontium and diseased periodontium with bitewing and periapical radiographs and clinician recorded CAL were utilized. Data utilized was from July 1, 2016 through January 30, 2020. 80,326 images were used for training, 12,901 images were used for validation and 10,687 images were used to compare non-inpainted methods to inpainted methods for CAL predictions. Statistical analyses were mean bias error (MBE), mean absolute error (MAE) and Dunn's pairwise test comparing CAL at p=0.05.Comparator p-values demonstrated statistically significant improvement in CAL prediction accuracy between corresponding inpainted and non-inpainted methods with MAE of 1.04mm and 1.50mm respectively. The Dunn's pairwise test indicated statistically significant improvement in CAL prediction accuracy between inpainted methods compared to their non-inpainted counterparts, with the best performing methods achieving a Dunn's pairwise value of -63.89.This study demonstrates the superiority of using a generative adversarial inpainting network with partial convolutions to predict CAL from bitewing and periapical images.Artificial intelligence was developed and utilized to predict clinical attachment level compared to clinical measurements. A generative adversarial inpainting network with partial convolutions was developed, tested and validated to predict clinical attachment level. The inpainting approach was found to be superior to non-inpainted methods and within the 1mm clinician-determined measurement standard.

BackgroundAn increasing number of healthcare quality measures are designed for annual reporting. These measures require an entire year of data to accurately report the percentage of patients who met the measure. Annual measures give providers latitude to prioritize clinical workload and patient needs; however, they do not provide a direct means to monitor performance throughout the reporting year. Although there are many possible methods for measuring annual measures at finer-grained timescales, our applied work showed that the most obvious methods could give a misleading and inaccurate view of progress throughout the year. Neither the definitions of the annual measures, nor the research literature, provided any guidance on the best methods for interim monitoring of annual measures.ObjectiveOur objective was to evaluate four different methods for monitoring annually reported quality measures monthly to best predict year-end performance throughout the reporting year.MethodsWe developed four methods for monitoring annual measures by month: 1) Monthly Proportion: The proportion of patients with one or more encounters in the month who still needed to meet the measure at their first encounter of the month and met the measure by the end of the month; (2) Monthly Lookback Proportion: The proportion of patients seen in the month who met the measure by the end of the month, regardless of whether it was met in that month or previously in the reporting year; (3) Rolling 12 Month: The annual measure reported as if each month was the twelfth month of a twelve-month reporting period; and (4) YTD (Year-to-Date) Cumulative: The proportion of patients with one or more visits from the start of the reporting year through the month who satisfy the measure. We applied each method to two annual dental quality measures using data from two reporting years, and four different dental sites. We used mean squared error (MSE) to evaluate year-end predictive performance.ResultsMethod 3 (Rolling 12 Month) had the lowest MSE in 11 out of 16 cases (2 measures X 2 years X 4 sites) and lowest total MSE (262.39) across all 16 cases. In 5 of the 16 cases, YTD Cumulative had the lowest MSE.ConclusionsThe Rolling 12 Month method was best for predicting the year-end value across both measures and all four sites.

BackgroundCare coordination is a key strategy used to improve health outcomes and efficiency, yet there are limited examples in dentistry. A large dental accountable care organization piloted care coordination by retraining existing administrative staff to coordinate the care of high-risk patients. Following the pilot’s success, a formal “dental care advocate” (DCA) role was integrated system-wide. The goal of this new role is to improve care, patient engagement, and health outcomes while integrating staff into the clinical care team. We aim to describe the process of DCA role implementation and assess staff and clinician perceptions about the role pre- and post-implementation.MethodsGuided by the Consolidated Framework for Implementation Research, semi-structured interviews with clinical and operational administrative staff and observation at the company-wide training session were combined with pre- and post-implementation electronic surveys. Descriptive statistics and mean scores were tested for significance between each survey sample (t-tests), and qualitative data were thematically analyzed.ResultsWith preliminary evidence from the pilot and strong executive support, a dedicated leadership team executed a stepwise rollout of the DCA role over 6 months. Success was facilitated by an organizational culture of frequent interventions deployed rapidly through a centralized system, along with supportive buy-in from managerial teams and high staff acceptance and enthusiasm for the DCA role before implementation. Following implementation, significant changes in attitudes and beliefs about the role were measured, though managers held stronger positive impressions than DCAs. DCAs reported high confidence in new skills and dental knowledge post-implementation, including motivational interviewing and the ability to confidently answer patients’ questions about their oral health. Overall, the fast-paced implementation of this new role was well received, although consistent and significant differences in mean attitudes between managers and DCAs indicate more work to fine-tune the role is needed.ConclusionsSuccessful implementation of the new DCA role was facilitated by a strong organizational commitment to team-based dentistry and positive impressions of care coordination among staff and managers. Upskilling existing administrative staff with the necessary training to manage some high-risk patient needs is one method that can be used to implement care coordination efforts in dentistry.

Objectives Learning health-care systems are foundational for measuring and achieving value in oral health care. This article describes the components of a preventive dental care program and the quality of care in a large dental accountable care organization. Methods A retrospective study design describes and evaluates the cross-sectional measures of process of care (PoC), appropriateness of care (AoC), and outcomes of care (OoC) extracted from the electronic health record (EHR), between 2014 and 2019. Annual and composite measures are derived from EHR-based clinical decision support for risk determination, diagnostic and treatment terminology, and decayed-missing-filled-teeth (DMFT) measures. Results Annually, 253,515 ± 27,850 patients were cared for with 618,084 ± 80,559 visits, 209,366 ± 22,300 exams, and 2,072,844 ± 300,363 clinical procedures. PoC metrics included provider adherence (98.3 percent) in completing caries risk assessments and patient receipt (96.9 percent) of a proactive dental care plan. AoC metrics included patients receiving prevention according to the risk-based protocol. The percent of patients at risk for caries receiving fluoride varnish was 95.4 ± 0.4 percent. OoC metrics included untreated decay and new decay. The 6-year average prevalence of untreated decay was 11.3 ± 0.3 percent, and average incidence of new decay was 13.6 ± 0.5 percent, increasing with risk level: low = 7.5 percent, medium = 18.8 percent, high = 29.4 percent, and extreme = 28.1 percent. Conclusions The preventive dental care system demonstrates excellent provider adherence to the evidence-based prevention protocol, with measurably better dental outcomes by patient risk compared to national estimates. These achievements are enabled by a value-centric, accountable model of care and incentivized by a compensation model aligned with performance measures.

Natalie B Hastings,1 Linda S Centore,2 Stuart A Gansky,3 Frederick C Finzen,4 Joel M White,5 Eric Wong,6 Grayson W Marshall,7 Lisa Chung,3 Elsbeth Kalenderian3 1Division of Clinical General Dentistry, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 2Division of Behavioral Sciences & Community Dental Education, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 3Division of Oral Epidemiology & Dental Public Health, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 4Division of Prosthodontics, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 5Division of Preclinical Simulation, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 6Division of Endodontics, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 7Division of Biomaterials and Bioengineering, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA Purpose: We report on an accelerated and effective way of assimilating a new leader into a team at a large academic dental school department.Methods: At University of California, San Francisco (UCSF), a new Chair was recruited through a national search to lead its largest department in the School of Dentistry. Two months after arrival, the new Chair embarked on a process of leadership assimilation among her executive team, facilitated by a professional consultant. Within four weeks, team members participated in one-on-one interviews with the professional facilitator consultant and then completed the leadership assimilation questionnaire and returned it electronically to the facilitator. The facilitator then summarized all answers into themes and met with the team members without the Chair to debrief. Thereafter, the facilitator met with the Chair to discuss the major themes. Next, the Chair met with the team members in a facilitated session to discuss the results and negotiate a path forward.Results: Approximately half of the feedback described the “how” of leadership: comments on communication, building relationships, building trust, and understanding UCSF history. The remaining half described the “what”: comments on vision, strategy, and operations. Team members indicated that the first debriefing session was helpful to alleviate initial anxiety and to start building team spirit. The session with the Chair was perceived as open and fruitful in which team members were able to express their concerns and hopes for the Department, while the Chair showed commitment to the team and the communication process.Conclusion: Leader assimilation allows teams to share their expectations and anxieties with the new leader early in the relationship in an open way, before new habits and beliefs are formed. Conversely, for the leader, it effectively and efficiently allows a window into the team members’ thinking at a critical time period when otherwise first impressions occur. With a safe space created for open communication, the process allowed siloed individual division leaders to move toward a cohesive group while at the same time solidifying a commitment to the success of the new leader. Keywords: dental school, leadership, new leader assimilation, feedback, team, transition

Background Standardized dental diagnostic terminologies (SDDxTs) were introduced decades ago. Their use has been on the rise, accompanying the adoption of electronic health records (EHRs). One of the most broadly used terminologies is the Dental Diagnostic System (DDS). Our aim was to assess the adoption of SDDxTs by US dental schools by using the Rogers diffusion of innovations framework, focusing on the DDS. Methods The authors electronically surveyed clinic deans in all US dental schools (n = 61) to determine use of an EHR and SDDxT, perceived barriers to adoption of an SDDxT, and the effect of implementing an SDDxT on clinical productivity. Results The response rate was 57%. Of the 35 responses, 91% reported using an EHR to document patient care, with 84% using axiUm; 41% used the DDS. Fifty-four percent of those who did not use an SDDxT had considered adopting the DDS, but 38% had not, citing barriers such as complexity and compatibility. Conclusions Adoption of an SDDxT, particularly the DDS, is on the rise. Nevertheless, a large number of institutions are in the Rogers late majority and laggards categories with respect to adoption. Several factors may discourage adoption, including the inability to try out the terminology on a small scale, poor usability within the EHR, the fact that it would be a cultural shift in practice, and a perception of unclear benefits. However, the consolidation of the DDS and American Dental Association terminology efforts stands to encourage adoption. Practical Implications The successful adoption of dental innovation depends not only on the intrinsic merit of the innovation, as some useful innovations do not achieve widespread traction. As such, it is important for health care providers to understand how to disseminate their ideas in order to ensure traction and widespread adoption.

Contains fulltext : 229166.pdf (Publisher’s version ) (Closed access) OBJECTIVES: Despite a significant national investment in oral health, there is little understanding of the return in terms of quality. Value-based payments aim to refocus provider reimbursement based on the value created to the patient. Our objectives were to apply a set of dental quality measures to help determine the value of preventive dental care provided to children at two academic dental school clinics. METHODS: We queried the institutional electronic health records (EHRs) for patients between the ages of 6-14 years with sealable first or second permanent molars, determined caries risk status, identified if dental sealants were placed, and finally if the teeth showed evidence of new caries experience. In order to determine the cost-effectiveness of EHR-based triage of applying dental sealants, we calculated the incremental cost-effectiveness ratio (ICER) for the dental quality measures supported sealing program. RESULTS: Between the two academic sites, there were 6,155 unique children for a total of 12,302 eligible teeth without a sealant and 32,811 eligible teeth with a sealant. Teeth without a sealant were more likely to have decay (4.8 percent) than those with a sealant (1.7 percent). At both sites, patients with high caries risk were more likely to benefit from sealants compared to those patients with low risk. CONCLUSION: Implementation of caries risk stratified fissure sealant quality measures demonstrates the potential for extracting better value in oral health care.

Background: Patients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs). Methods: We developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs. Results: Of the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room. Conclusion: By developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future. Knowledge Transfer Statement: A retrospective review of patients’ health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record–based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered.

Introduction: To fill the void created by insufficient dental terminologies, a multi-institutional workgroup was formed among members of the Consortium for Oral Health Research and Informatics to develop the Dental Diagnostic System (DDS) in 2009. The adoption of dental diagnosis terminologies by providers must be accompanied by rigorous usability and validity assessments to ensure their effectiveness in practice. Objectives: The primary objective of this study was to describe the utilization and correct use of the DDS over a 4-y period. Methods: Electronic health record data were amassed from 2013 to 2016 where diagnostic terms and Current Dental Terminology procedure code pairs were adjudicated by calibrated dentists. With the resultant data, we report on the 4-y utilization and validity of the DDS at 5 dental institutions. Utilization refers to the proportion of instances that diagnoses are documented in a structured format, and validity is defined as the frequency of valid pairs divided by the number of all treatment codes entered. Results: Nearly 10 million procedures ( n = 9,946,975) were documented at the 5 participating institutions between 2013 and 2016. There was a 1.5-fold increase in the number of unique diagnoses documented during the 4-y period. The utilization and validity proportions of the DDS had statistically significant increases from 2013 to 2016 ( P < 0.0001). Academic dental sites were more likely to document diagnoses associated with orthodontic and restorative procedures, while the private dental site was equally likely to document diagnoses associated with all procedures. Overall, the private dental site had significantly higher utilization and validity proportions than the academic dental sites. Conclusion: The results demonstrate an improvement in utilization and validity of the DDS terminology over time. These findings also yield insight into the factors that influence the usability, adoption, and validity of dental terminologies, raising the need for more focused training of dental students. Knowledge Transfer Statement: Ensuring that providers use standardized methods for documentation of diagnoses represents a challenge within dentistry. The results of this study can be used by clinicians when evaluating the utility of diagnostic terminologies embedded within the electronic health record.

Background In recent years, several state dental programs, researchers and the Dental Quality Alliance (DQA) have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences. Some of these measures have been tested and validated for various population groups. However, there are some unintended consequences and challenges with quality measurement in dentistry as observed from our previous work on refining and transforming dental quality measures into e-measures. Main body Some examples of the unintended consequences and challenges associated with implementing dental quality measures include: a de-emphasis on patient-centeredness with process-based quality measures, an incentivization of unethical behavior due to fee-for-service reimbursement systems, the risk of compromising patient and provider autonomy with plan-level measures, a disproportionate benefits of dental quality measurement going toward payers, and the risk of alienating smaller dental offices due to the resource-intensive nature of quality measurement. Conclusion As our medical counterparts have embraced quality measurement for improved health outcomes, so too must the dental profession. Our ultimate goal is to ensure the delivery of high quality, patient-centered dental care and effective quality measurement is the first step. By continuously monitoring the performance of dental quality measures and their continued refinement when unintended consequences are observed, we can improve patient and population health outcomes.

ObjectivesThe study evaluates the efficacy to remineralize artificial and natural dentin lesions through restorative dental procedures that include the Polymer-Induced Liquid Precursor (PILP) method comprising polyaspartic acid (pAsp).MethodsNovel ionomeric cement compositions based on bioglass 45S5 and pAsp mixtures, as well as conditioning solutions (conditioner) containing 5 mg/mL pAsp, were developed and tested on demineralized dentin blocks (3-4 mm thick) on shallow and deep lesions with the thickness of 140 μm ± 50 and 700 μm ± 50, respectively. In the first treatment group, 20 μL of conditioner was applied to demineralized shallow (n = 3) and deep (n = 3) lesion specimens for 20 s before restoration with glass ionomer cement (RMGIC). For the PILP cement treatment group, cement was applied onto the wet surface of the demineralized specimen for both shallow (n = 3) and deep (n = 3) artificial lesions after the application of the conditioner and before the final restoration. Sample groups were compared to RMGIC restoration, for both shallow and deep lesions (n = 3 each) and treatments in PILP-solution (n = 3 for deep lesions) without restoration for 4 weeks. All of the restored specimens were immersed in simulated body fluid (SBF) solution for 2 weeks and 4 weeks for shallow and deep lesions respectively to allow for remineralization. The artificial lesion specimens were evaluated for changes in the nanomechanical profile (E-modulus and hardness) using nanoindentation. Shallow lesions were analyzed by SEM under vacuum for changes in morphology caused by PILP treatments. Also, a pilot study on human third molars with moderate lesions in dentin (n = 3) was initiated to test the efficacy of treatments in natural lesions based on mineral densities using microcomputed tomography (μCT) at 0, 1, and 3 months.ResultsThis study showed that functional remineralization of artificial lesions using PILP-releasing restoratives occurred, indicated by an increase of the elastic modulus in shallow lesions and in the middle zone of deep artificial lesions. The mechanical improvement was significant when compared to RMGIC restoration without pAsp (P < 0.05). Nonetheless, recovery across artificial lesions was most significant when specimens were immersed into PILP-solution with restorative (P < 0.01). Furthermore, natural lesions increased in mineral volume content to a higher degree when the restorative treatment included the PILP-method (P < 0.05). However, none of the natural lesions recovered to full mineral degree regardless of the treatments.Clinical significance/conclusionThese findings indicate the benefit of PILP applications in the functional repair of dentin caries and illustrate the challenge to integrate the PILP-method into a restorative approach in minimally invasive dental procedures.

Three change drivers are being implemented to high standards of patient centric and evidence-based oral health care within the context of a large multispecialty dental group practice organization based on the commitment of the dental hygienist chief operating officer and her team. Background and purpose A recent environmental scan elucidated 6 change drivers that can impact the provision of oral health care. Practitioners who can embrace and maximize aspects of these change drivers will move dentistry forward and create future opportunities. This article explains how 3 of these change drivers are being applied in a privately held, accountable risk-bearing entity that provides individualized treatment programs for more than 417,000 members. To facilitate integration of the conceptual changes related to the drivers, a multi-institutional, multidisciplinary, highly functioning collaborative work group was formed. Methods and approach The document Dental Hygiene at a Crossroads for Change 1 inspired the first author, a dental hygienist in a unique position as chief operating officer of a large group practice, to pursue evidence-based organizational change and to impact the quality of patient care. This was accomplished by implementing technological advances including dental diagnosis terminology in the electronic health record, clinical decision support, standardized treatment guidelines, quality metrics, and patient engagement to improve oral health outcomes at the patient and population levels. The systems and processes used to implement 3 change drivers into a large multi-practice dental setting is presented to inform and inspire others to implement change drivers with the potential for advancing oral health. Conclusions Technology implementing best practices and improving patient engagement are excellent drivers to advance oral health and are an effective use of oral health care dollars. Improved oral health can be leveraged through technological advances to improve clinical practice.

A person's right to access his or her protected health information is a core feature of the U.S. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. If the information is stored electronically, covered entities must be able to provide patients with some type of machine-readable, electronic copy of their data. The aim of this study was to understand how academic dental institutions execute the Privacy Rule's right of access in the context of electronic health records (EHRs). A validated electronic survey was distributed to the clinical deans of 62 U.S. dental schools during a two-month period in 2014. The response rate to the survey was 53.2% (N=33). However, three surveys were partially completed, and of the 30 completed surveys, the 24 respondents who reported using axiUm as the EHR at their dental school clinic were the ones on which the results were based (38.7% of total schools at the time). Of the responses analyzed, 86% agreed that clinical modules should be considered part of a patient's dental record, and all agreed that student teaching-related modules should not. Great variability existed among these clinical deans as to whether administrative and financial modules should be considered part of a patient record. When patients request their records, close to 50% of responding schools provide the information exclusively on paper. This study found variation among dental schools in their implementation of the Privacy Rule right of access, and although all the respondents had adopted EHRs, a large number return records in paper format.

Objectives This study addresses a gap in the literature regarding dental patients' perceptions about safety at the dental office and their attitudes toward reporting safety concerns and experiences. Methods We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period. A 16-item questionnaire was distributed to the patients to assess (1) past safety concerns and experiences during dental visits; (2) factors affecting the future reporting of safety concerns and experiences; (3) overall concern about safety at the dental office; (4) overall perceptions that patients should report of safety concerns or experiences to dental providers and staff. Results A majority (63.5%) of dental patients were concerned about safety at the dental office, although only one-third of them shared their past safety concerns or experiences with their dental providers or clinic staff. Irrespective of their past experiences, most patients (96.9%) believed that patients should report any safety concerns or experiences to the clinic. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff. Conclusions Our findings suggest that dental patients are concerned about safety and can be valuable sources of data, when adequately engaged. The current level of patient reporting of safety concerns and/or experiences to clinic staff or care providers is not optimal for learning and improvement. Practical Implications Better patient engagement in safety activities will potentially increase our collective understanding of threats to safety. Therefore, dental clinics need to encourage patients to speak up about their safety concerns or experiences.

Caries indices, the basis of epidemiologic caries measures, are not easily obtained in clinical settings. This study’s objective was to design, test, and validate an automated program (Valid Electronic Health Record Dental Caries Indices Calculator Tool [VERDICT]) to calculate caries indices from an electronic health record (EHR). Synthetic use case scenarios and actual patient cases of primary, mixed, and permanent dentition, including decayed, missing, and filled teeth (DMFT/dmft) and tooth surfaces (DMFS/dmfs) were entered into the EHR. VERDICT measures were compared to a previously validated clinical electronic data capture (EDC) system and statistical program to calculate caries indices. Four university clinician-researchers abstracted EHR caries exam data for 45 synthetic use cases into the EDC and post-processed with SAS software creating a gold standard to compare the ­VERDICT-derived caries indices. Then, 2 senior researchers abstracted EHR caries exam data and calculated caries indices for 24 patients, allowing further comparisons to VERDICT indices. Agreement statistics were computed among abstractors, and discrepancies were resolved by consensus. Agreement statistics between the 2 final-phase abstractors and the VERDICT measures showed extremely high concordance: Lin’s concordance coefficients (LCCs) >0.99 for dmfs, dmft, DS, ds, DT, dt, ms, mt, FS, fs, FT, and ft; LCCs >0.95 for DMFS and DMFT; and LCCs of 0.92–0.93 for MS and MT. Caries indices, essential to developing primary health outcome measures for research, can be reliably derived from an EHR using VERDICT. Using these indices will enable population oral health management approaches and inform quality improvement efforts.

Background Quality improvement requires using quality measures that can be implemented in a valid manner. Using guidelines set forth by the Meaningful Use portion of the Health Information Technology for Economic and Clinical Health Act, the authors assessed the feasibility and performance of an automated electronic Meaningful Use dental clinical quality measure to determine the percentage of children who received fluoride varnish. Methods The authors defined how to implement the automated measure queries in a dental electronic health record. Within records identified through automated query, the authors manually reviewed a subsample to assess the performance of the query. Results The automated query results revealed that 71.0% of patients had fluoride varnish compared with the manual chart review results that indicated 77.6% of patients had fluoride varnish. The automated quality measure performance results indicated 90.5% sensitivity, 90.8% specificity, 96.9% positive predictive value, and 75.2% negative predictive value. Conclusions The authors’ findings support the feasibility of using automated dental quality measure queries in the context of sufficient structured data. Information noted only in free text rather than in structured data would require using natural language processing approaches to effectively query electronic health records. Practical Implications To participate in self-directed quality improvement, dental clinicians must embrace the accountability era. Commitment to quality will require enhanced documentation to support near-term automated calculation of quality measures.

The objective of this paper is to assess clinical dental providers' baseline knowledge and attitudes about the implementation of three clinical decision support (CDS) tools built into the electronic health record (EHR) of a multi-specialty group dental practice.An electronic survey designed to examine predisposing factors for acceptance of EHR-based tools, caries and periodontal disease management by risk assessment and a risk assessment-based Proactive Dental Care Plan, was distributed to all Willamette Dental Group (WDG) employees. The survey collected demographic data, along with measures of job experience and satisfaction, comfort with dental information technology, and attitudes and knowledge of each CDS tool. WDG provided data on site-level patient and financing mix, patient satisfaction data, employee role (e.g. dentist) and tenure with company. The survey was conducted 3 months prior to the rollout of the CDS tools in November 2013. The survey was distributed electronically to all WDG employees (n = 1166), of whom 58.5% (n = 682) were clinicians, located in 53 sites in Oregon, Washington and Idaho. The overall response rate was 79.8% (n = 930), with a response rate of 83.1% (n = 567) from all clinicians. Of these, 24.3% were general and specialist dentists (n = 138); 26.6% were dental hygienists (n = 151), and 49% were dental assistants (n = 278).The clinicians surveyed reported being highly amenable to implementation of the three CDS tools. Clinicians' attitudes reflected higher expected improvement in patient care and quality than in business processes due to the implementation. The clinician characteristics most strongly correlated with a positive attitude toward the CDS tool implementation (as measured on Likert scale 1 = low to 5 = high) included satisfaction with the EHR (0.499, p0.001), job satisfaction (0.458, p0.001), finding change to be exciting (0.398, p0.001), degree of control perceived over work (0.352, p0.001), and a perception of having adequate tools to get work done (0.340, p0.001). Higher reported frequency (scale 1 = never, 7 = always) of feeling burned out (-0.297, p0.001), feeling emotionally drained (-0.265, p0.001), and feeling work is a strain (-0.205, p0.001) had the greatest correlation with negative attitudes.This is the first study to examine dental provider attitudes toward the implementation of CDS tools incorporated within an electronic health record. Provider attitudes toward CDS tools can shape the entire implementation process for better or worse. This study contributes to the literature by providing an understanding of factors related to positive attitudes at the outset of a system change and can help guide organizational administrators to better prepare their workforce and organization for adoption of evidence-based dentistry tools such as a CDS system.

Background Attitudes and views are critical to the adoption of innovation. Although there have been broadening calls for a standardized dental diagnostic terminology, little is known about the views of private practice dental team members regarding the adoption of such a terminology. Methods The authors developed a survey by using validated questions identified through literature review. Domain experts’ input allowed for further modifications. The authors administered the final survey electronically to 814 team members at a multioffice practice based in the US Pacific Northwest. Results Response proportion was 92%. The survey had excellent reliability (Cronbach α coefficient = 0.87). Results suggested that participants showed, in general, positive attitudes and beliefs about using a standardized diagnostic terminology in their practices. Additional written comments by participants highlighted the potential for improved communication with use of the terminology. Conclusions Dental care providers and staff in 1 multioffice practice showed positive attitudes about the use of a diagnostic terminology; specifically, they believed it would improve communication between the dentist and patient, as well as among providers, while expressing some concerns about whether using standardized dental diagnostic terms helps clinicians to deliver better dental care. Practical Implications As the dental profession is advancing toward the use of standardized diagnostic terminology, successful implementation will require that dental team leaders prepare their teams by gauging their attitude about the use of such a terminology.

Objectives The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling. Methods We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts. Results Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice. Conclusions We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Background Although sealants are highly effective in preventing caries in children, placement rates continue to be low. The authors’ goals were to implement and assess the performance of 2 existing sealant quality measures against a manual audit of charts at 4 dental institutions and to identify measurement gaps that may be filled by using data from electronic health records. Methods The authors evaluated the performance of 2 quality measures designed for claims-based data: the Dental Quality Alliance (DQA) sealant measure, which includes patients at risk of developing elevated caries, and the Oregon Health Authority (OHA) sealant measure (irrespective of caries risk). The authors adapted and validated these measures at 4 sites: 3 dental schools and 1 large dental accountable care organization. Results The overall modified DQA and modified OHA measure scores in the 6- through 9-year-old age group were 37.0% and 31.6% and in the 10- through 14-year-old age group were 15.8% and 6.6%, respectively. Results from the manual review of charts showed that 67.6% of children who did not receive sealants did not have any teeth to seal because their molars had not yet erupted, had been extracted, had been sealed previously, or had existing caries or restorations. Conclusions Both the DQA and OHA measures, which rely mainly on Current Dental Terminology procedure codes, led to underestimation of the care delivered from a practice perspective. Future sealant quality measures should exclude patients whose teeth cannot be sealed. Practical Implications This study’s results support the suitability of using electronic health record data for assessing the quality of oral health care, particularly for measuring sealant placement in children.

The routine use of standardized diagnostic terminologies (DxTMs) in dentistry has long been the subject of academic debate. This paper discusses the strategies suggested by a group of dental stakeholders to enhance the uptake of DxTMs. Through unstructured interviewing at the 'Toward a Diagnosis-Driven Profession' National Conference held on 19 March 2016 in Los Angeles, CA, USA participants were asked how enthusiastic they were about implementing and consistently using DxTMs at their work. They also brainstormed on strategies to improve the widespread use of DxTMs. Their responses are summarized by recursive abstraction and presented in themes. Conference participants were very enthusiastic about using a DxTM in their place of work. Participants enumerated several strategies to make DxTMs more appealing including: the use of mandates, a value proposition for providers, communication and education, and integration with EHRs and existing systems. All groups across the dental healthcare delivery spectrum will need to work together for the success of the widespread and consistent use of DxTMs. Understanding the provider perspective is however the most critical step in achieving this goal, as they are the group who will ultimately be saddled with the critical task of ensuring DxTM use at the point of care.

Standardized dental diagnostic terminologies (SDDxTs) were introduced decades ago. Their use has been on the rise, accompanying the adoption of electronic health records (EHRs). One of the most broadly used terminologies is the Dental Diagnostic System (DDS). Our aim was to assess the adoption of SDDxTs by US dental schools by using the Rogers diffusion of innovations framework, focusing on the DDS.The authors electronically surveyed clinic deans in all US dental schools (n = 61) to determine use of an EHR and SDDxT, perceived barriers to adoption of an SDDxT, and the effect of implementing an SDDxT on clinical productivity.The response rate was 57%. Of the 35 responses, 91% reported using an EHR to document patient care, with 84% using axiUm; 41% used the DDS. Fifty-four percent of those who did not use an SDDxT had considered adopting the DDS, but 38% had not, citing barriers such as complexity and compatibility.Adoption of an SDDxT, particularly the DDS, is on the rise. Nevertheless, a large number of institutions are in the Rogers late majority and laggards categories with respect to adoption. Several factors may discourage adoption, including the inability to try out the terminology on a small scale, poor usability within the EHR, the fact that it would be a cultural shift in practice, and a perception of unclear benefits. However, the consolidation of the DDS and American Dental Association terminology efforts stands to encourage adoption.The successful adoption of dental innovation depends not only on the intrinsic merit of the innovation, as some useful innovations do not achieve widespread traction. As such, it is important for health care providers to understand how to disseminate their ideas in order to ensure traction and widespread adoption.

Although standardized terminologies such as the International Classification of Diseases have been in use in medicine for over a century, efforts in the dental profession to standardize dental diagnostic terms have not achieved widespread acceptance. To address this gap, a standardized dental diagnostic terminology, the EZCodes, was developed in 2009. Fifteen dental education institutions in the United States and Europe have implemented the EZCodes dental diagnostic terminology. This article reports on the utilization and valid entry of the EZCodes at three of the dental schools that have adopted this standardized dental diagnostic terminology. Electronic data on the use of procedure codes with diagnostic terms from the three schools over a period from July 2010 to June 2011 were aggregated. The diagnostic term and procedure code pairs were adjudicated by three calibrated dentists. Analyses were conducted to gain insight into the utilization and valid entry of the EZCodes diagnostic terminology in the one-year period. Error proportions in the entry of diagnostic term (and by diagnostic category) were also computed. In the twelve-month period, 29,965 diagnostic terms and 249,411 procedure codes were entered at the three institutions resulting in a utilization proportion of 12 percent. Caries and periodontics were the most frequently used categories. More than 1,000 of the available 1,321 diagnostic terms were never used. Overall, 60.5 percent of the EZCodes entries were found to be valid. The results demonstrate low utilization of EZCodes in an electronic health record and raise the need for specific training of dental providers on the importance of using dental diagnostic terminology and specifically how to use the terms in the electronic record. These findings will serve to increase the use/correct use of the EZCodes dental diagnostic terminology and ultimately create a reliable platform for undertaking clinical, outcomes, and quality improvement-related research.

Background Although some patients experience adverse events (AEs) resulting in harm caused by treatments in dentistry, few published reports have detailed how dental providers describe these events. Understanding how dental treatment professionals view AEs is essential to building a safer environment in dental practice. Methods The authors interviewed dental professionals and domain experts through focus groups and in-depth interviews and asked them to identify the types of AEs that may occur in dental settings. Results The initial interview and focus group findings yielded 1,514 items that included both causes and AEs. In total, 632 causes were coded into 1 of the 8 categories of the Eindhoven classification, and 882 AEs were coded into 12 categories of a newly developed dental AE classification. Interrater reliability was moderate among coders. The list was reanalyzed, and duplicate items were removed leaving a total of 747 unique AEs and 540 causes. The most frequently identified AE types were "aspiration and ingestion" at 14% (n = 142), "wrong-site, wrong-procedure, wrong-patient errors" at 13%, "hard-tissue damage" at 13%, and "soft-tissue damage" at 12%. Conclusions Dental providers identified a large and diverse list of AEs. These events ranged from "death due to cardiac arrest" to "jaw fatigue from lengthy procedures." Practical Implications Identifying threats to patient safety is a key element of improving dental patient safety. An inventory of dental AEs underpins efforts to track, prevent, and mitigate these events.

Objective This study assesses dental clinicians' pre- and post-implementation attitudes, skills, and experiences with three clinical decision support (CDS) tools built into the electronic health record (EHR) of a multi-specialty group dental practice. Methods Electronic surveys designed to examine factors for acceptance of EHR-based CDS tools including caries management by risk assessment (CAMBRA), periodontal disease management by risk assessment (PEMBRA) and a risk assessment-based Proactive Dental Care Plan (PDCP) were distributed to all Willamette Dental Group employees at 2 time points; 3 months pre-implementation (Fall 2013) and 15 months after implementation (winter 2015). The surveys collected demographics, measures of job experience and satisfaction, and attitudes toward each CDS tool. The baseline survey response rate among clinicians was 83.1% ( n = 567) and follow-up survey response rate was 63.2% ( n = 508). Among the 344 clinicians who responded to both before and after surveys, 27% were general and specialist dentists, 32% were dental hygienists, and 41% were dental assistants. Results Adherence to the CDS tools has been sustained at 98%+ since roll-out. Between baseline and follow-up, the change in mean attitude scores regarding CAMBRA reflect statistically significant improvement in formal training, knowing how to use the tools, belief in the science supporting the tools, and the usefulness of the tool to motivate patients. For PEMBRA, statistically significant improvement was found in formal training, knowing how to use the tools, belief in the science supporting the tools, with improvement also found in belief that the format and process worked well. Finally, for the PDCP, significant and positive changes were seen for every attitude and skill item scored. A strong and positive correlation with post-implementation attitudes was found with positive experiences in the work environment, whereas a negative correlation was found with workload and stress. Clinicians highly ranked a commitment to evidence-based care and sense that the tools were helping to improve patient care, health, and experience as motivations to use the tools. Peer pressure, fears about malpractice, and incentive pay were rated the lowest among the motivation factors. Conclusion This study shows that CDS tools built into the EHR can be successfully implemented in a dental practice and widely accepted by the entire clinical team. Achieving a high level of adherence to use of CDS can be done through adequate training, alignment with the mission and purpose of the organization, and is compatible with an improved work environment and clinician satisfaction.

An evidence-based periodontal disease risk assessment and diagnosis system has been developed and combined with a clinical decision support and management program to improve treatment and measure patient outcomes. Background There is little agreement on a universally accepted periodontal risk assessment, periodontal diagnosis, and treatment management tool and their incorporation into dental practice to improve patient care. This article highlights the development and use of a practical periodontal management and risk assessment program that can be implemented in dental settings. Methods The approach taken by Willamette Dental Group to develop a periodontal disease risk assessment, periodontal diagnosis, and treatment management tool is described using evidence-based best practices. With goals of standardized treatment interventions while maintaining personalized care and improved communication, this process is described to facilitate its incorporation into other dental settings. Conclusions Current electronic health records can be leveraged to enhance patient-centered care through the use of risk assessments and standardized guidelines to more effectively assess, diagnose, and treat patients to improve outcomes. Dental hygienists, and other committed providers, with their emphasis on prevention of periodontal disease can be principal drivers in creation and implementation of periodontal risk assessments and personalized treatment planning. Willamette Dental Group believes that such evidence-based tools can advance dentistry to new diagnostic and treatment standards.

As dental schools continue to seek the most effective ways to provide clinical education for students, it is important to track the effects innovations have on students' clinical experience to allow for quantitative comparisons of various curricula. The aim of this study was to compare the impact of three successive clinical curricula on students' experience at one U.S. dental school. The three were a discipline-based curriculum (DBC), a comprehensive care curriculum (CCC), and a procedural requirement curriculum plus externships (PRCE). Students' clinic experience data from 1992 to 2013 were analyzed for total experience and in five discipline areas. Clinic experience metrics analyzed were patient visits (PVs), relative value units (RVUs), and equivalent amounts (EQAs). A minimum experience threshold (MET) and a high experience threshold (HET) were set at one standard deviation above and below the mean for the DBC years. Students below the MET were designated as low achievers; students above the HET were designated as high achievers. The results showed significant differences among the three curricula in almost all areas of comparison: total PVs, total EQAs, total RVUs, RVUs by discipline, and number of high and low achievers in total clinical experience and by discipline. The comprehensive care approach to clinical education did not negatively impact students' clinical experience and in many cases enhanced it. The addition of externships also enhanced student total clinical experience although more study is needed to determine their effectiveness. The insights provided by this study suggest that the methodology used including the metrics of PVs, EQAs, and RVUs may be helpful for other dental schools in assessing students' clinical experience.

Dentists, like physicians, routinely perform highly technical and risky procedures in complex environments, work in teams and use a multitude of devices and tools. Health care is considered one of the least safe industries—much less safe than the aviation and oil and gas industries—and less safe than regulated activities such as driving. Dentistry has seen several documented deaths, including, late in 2011, the death of a 17year-old whose heart rate and blood oxygen dropped to fatally low levels during third-molar extraction. Furthermore, even less grave events, such as the extraction of the wrong tooth, affect the quality of care. It is documented that reported errors in medicine are fewer than the actual occurrences; this also may be true in dentistry. Yet, the patient safety and quality revolution that has established itself worldwide in medicine has not yet taken hold in dentistry. We must have the courage to commit to change. Our medical colleagues blazed this trail. More than a decade ago, the Institute of Medicine’s Committee on Quality of Health Care in America released two reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which emphasized the importance of transformational reform in the health care system and that changes around the margin would be inadequate.