Practice success is defined across the four ‘dimensions’ of oral health, patient satisfaction, job satisfaction and financial profit. It is suggested that the ‘secret’ of success in dental practice is to make patient (customer) satisfaction the primary focus. Not a very earth shattering or surprising ‘secret’ perhaps! This is hardly a new idea, and not a concept restricted to dental practice. This principle applies to all businesses. This series of articles reviews evidence from across a broad spectrum of publications: from populist business publications through to refereed scientific papers, this ‘secret’ seems to be confirmed. The evidence for which aspects of our service are most important in achieving patient satisfaction (and therefore success) is explored.
Clinical Relevance: Good oral health outcomes for patients are defined as the primary purpose of dental practice and, therefore, an essential dimension of success. The link between positive patient perceptions of general care and their own oral health to practice success is explored.
Article
Oral health as a dimension of success
As discussed in article 1, the primary purpose of dental practice is to support patients in achieving optimal oral health.
The Department of Health in England,1 in 2005, defined oral health as:
‘A standard of health of the oral and related tissues, which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being’.
This definition clarifies the importance of favourable patient self perception (or ‘patient satisfaction’ with their oral health) in achieving good oral health. Who, other than the patient, could determine his/her ability to eat, speak and socialize without discomfort or embarrassment? So, in the very definition of oral health, we are once more seeing confirmation that the fundamental ‘secret of success’ is patient satisfaction.
Locker2 was critical of the predominantly clinical focus in assessing oral health. He made a strong case to move towards measurements of impairment, disability and handicap caused by oral disease. Ultimately, the patient will be the best judge of these impacts. This paper seemed to ‘set the scene’ for Slade and Spencer's work in 1994. The Oral Health Impact Profile (OHIP), with 49 questions across seven dimensions, was designed by Slade and Spencer.3 It is essentially a questionnaire designed to be used to measure patient perceptions of impact of oral health issues on their lives. They compiled the original questionnaire from interviews with 64 patients from Adelaide, South Australia. The 64 subjects were deliberately selected to have experienced a range of oral diseases with consequent social impact. Initially, this group of patients made a total of 535 statements, using their own words, about the consequences of oral disorders. The original 535 statements were collated into these seven dimensions drawn from a model proposed by Locker in his conceptual paper referred to in Table 1.2
Dimension
Questions concerning
Functional limitation
Trouble pronouncing words, worsened taste
Physical pain
Aching in mouth, discomfort eating food
Psychological discomfort
Feeling self-conscious or tense
Physical disability
Interrupted meals or poor diet
Psychological disability
Difficulty relaxing, embarrassment
Social disability
Irritability, difficulty in doing usual jobs
Handicap
Life less satisfying, inability to function
Locker had based these dimensions on the World Health Organization's classification of impairments, disabilities and handicaps. This index is therefore solely concerned with patient perceptions. We can only admire the extent, attention to detail and broad scope of this work. However, Slade and Spencer themselves state:3
‘The 49 questions constitute a lengthy questionnaire, and the average time for administration by an interviewer is 17 minutes’.
A shorter 14 question version was developed by Slade.4 This is reproduced in Table 2. However, many busy practices would probably consider even 14 questions to be too many to assess their patients’ satisfaction with their oral health efficiently?
Have you had any trouble pronouncing any words because of problems with your teeth mouth and dentures?
Have you felt that your sense of taste has worsened because of problems with your teeth, mouth or dentures?
Have you had painful aching in your mouth?
Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures?
Have you been self-conscious because of your teeth, mouth or dentures?
Have you felt tense because of problems with your teeth, mouth or dentures?
Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?
Have you had to interrupt meals because of problems with your teeth, mouth or dentures?
Have you found it difficult to relax because of problems with your teeth, mouth or dentures?
Have you been embarrassed because of trouble with your teeth, mouth or dentures?
Have you been a bit irritable with other people because of problems with your teeth, mouth or dentures?
Have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures?
Have you felt that life in general was less satisfying because of problems with your teeth mouth or dentures?
Have you been totally unable to function because of problems with your teeth, mouth or dentures?
Burke and Wilson5 described three patient perception questions about comfort, function and appearance as part of their index. This was the Oral Health Index (OHX). The index also describes scoring protocols for the assessment of caries, wear, periodontal disease, occlusion and soft tissue health. An assessment of the integrity of existing restorations is included. Burke et al6 described a modification of the OHX (the Denplan Excel Oral Health Score or OHS) which maintained the three questions and allocated 24% of the total score to patient perceptions. The remaining 76% of the score was allocated to the clinical examination of periodontal health, wear of teeth and restorations, the occlusion, caries status, and soft tissue health using very similar protocols to the OHX. This weighting of the score generally met with approval from the 239 dentists (77% response rate) who responded to a questionnaire at the end of the pilot period for Denplan Excel Accreditation. The protocol for this index suggests that dentists ask the following three questions in order to assess comfort, function and appearance:
Is your mouth free from pain?
Can you comfortably chew an unrestricted diet?
Are you happy with the appearance of your teeth?
The use of this index is a central aspect of the Denplan Excel Accreditation. As of December 2010, more than 800 dentists were accredited. Since its introduction ten years ago, the OHS has been used as part of several million patient examinations. In this regard, Ireland et al7 also concluded that the following should be three of 10 factors recommended in their minimum dataset:
Presence of oral pain;
Patient satisfaction with appearance;
Patient satisfaction with function.
These factors can only be assessed by patient feedback. The full dataset included similar clinical criteria to those in the OHS and OHX.
The evidence is therefore continuing to confirm the importance of patient satisfaction in assessing success levels with oral healthcare. The literature also points towards a three issue minimum dataset on patient perception of oral health.
Readers may now be wondering about the importance of the technical competence of dental teams in success? Is this being ignored? For patient readers the full importance will be revealed in article 4.
If you decide to fly with a particular airline your perceptions are all that really matters in assessing the standard of customer care on offer. You will have probably also made judgements about the technical competence of the pilots and maintenance crew. This might be, in part, based on a notion that the industry monitors their technical competence and sets professional standards? You will certainly also want to perceive that these professionals are competent perhaps by the way they look and sound? However, with your limited knowledge of the technical aspects of flying, you will probably rely on the authorities to set and maintain these standards. The same applies in dental practice. We, of course, have our own set of professional standards.
In 2006, the Faculty of General Dental Practice (UK) of The Royal College of Surgeons of England published Standards in Dentistry, edited by Eaton.8 By reference to other publications on standards, and websites, this manual covers a wide range of structure, process and outcome expectations. Seventeen different clinical topics have defined standards published in detail. Outcomes as a result of care and treatment are graded as follows:
Grade A – Ideal. A standard of excellence has been achieved.
Grade B – Acceptable. The minimum acceptable standard, below which there is potential for damage to the patient.
Grade C – Unacceptable. The patient concerned has either been damaged or there is potential for them to be damaged.
The detailed text describing how this A, B, C grading can be applied to the 17 clinical topics subdivides each topic into six areas. This means that 306 possible clinical outcomes are defined. There are therefore 18 outcomes described for each of the 17 topics. Table 3 shows the proportion of described standards for five of the clinical topics requiring some patient feedback in the assessment.
Patient perceptions, as a means of assessment, are therefore a very important part of the protocols. In this sample, well over 50% of the described standards require some patient feedback during assessment. This feedback was generally about comfort, function or appearance. So, even professional standards include patient satisfaction as a vital element of assessment.
Conclusion
The primary purpose of a dental practice is to support its patients towards optimal oral health. Achieving this objective is therefore fundamental to practice success.
Patient satisfaction with his/her oral health is a partial and essential indicator of success in this dimension. (Clinical examination and special tests are, of course, needed to assess success fully.)
As a minimum, patient feedback on his/her comfort, function and aesthetics is required to assess this aspect of success.
