Patients’ comfort with and receipt of health risk assessments during routine dental visits: Results from the South Atlantic region of The US National Dental Practice-Based Research Network

Abstract

Objectives:

To understand patients’ comfort with health risk assessments (HRAs) and patient and dentist factors associated with the provision of HRAs.

Methods:

In this cross-sectional study, 857 patients seen by 30 dental practitioners in the United States National Dental Practice-Based Research Network reported their comfort receiving HRA for six risk factors (tobacco use, alcohol use, dietary sugar intake, human immunodeficiency virus risks, human papillomavirus risks, existing medical conditions) and whether they discussed any of the risk factors during their visits. Multi-level logistic models were used to examine the impacts of patient, practitioner, practice characteristics on the (1) number of risk factors patients were comfortable discussing and (2) number of risk factors assessed in the current dental visit.

Results:

Only a small percentage (4%) of patients reported being uncomfortable receiving any HRA during their dental visits. However, over half of the patients (53%) reported that they did not receive any HRAs during the current visit. In the regression analyses, patients who were older, male, and from the suburban were more likely to be comfortable with more HRAs. Dentists were more likely to provide HRA if they were younger, not non-Hispanic white, less likely to feel that providing HRAs was beyond their scope of practice, yet more likely to feel occasional discomfort in providing HRA.

Conclusions:

Interventions should focus on reducing dental practitioner perception that conducting HRAs is beyond their scope of practice and standardizing screening assessments for multiple risk factors.

INTRODUCTION

Policy makers, payers, health systems, clinicians and communities are increasingly advocating for better integration of primary medical care and dental care with shared care arrangements and a broadened view of a patient’s care team.^1–5 Bidirectional risk prevention and care management, in which oral health needs are assessed in primary medical care settings and general health risk factors are assessed in dental settings, are instrumental in comprehensively addressing patients’ health needs. Increasing opportunities for health risk assessments, prevention, and early intervention regardless of care setting have great potential to improve health.^6,7

Health risk assessments (HRAs) are a key component of prospective health care, which emphasizes prevention, screening, and preemptive intervention to reduce the morbidity and mortality associated with risk behaviors.⁸ Conducting HRAs is the first step in identifying individual health risks to better inform overall diagnoses and treatment plans and to ensure that appropriate counseling and referrals are made. Health care provider counseling is effective in achieving behavioral change for risk behaviors such as smoking, alcohol misuse, and sexual risk taking.⁹ Despite the importance of HRAs and their benefit, numerous studies have documented low levels (3–25%) of health risk behavior assessment in primary-care settings.^10,11 Regardless, there is growing evidence that providing HRA for particular conditions (e.g., diabetes, tobacco use) in dentists’ offices could increase opportunities to provide counseling and referrals for identified risks.^12–14

Prior research explored dentists’ perspectives on conducting HRAs and identified barriers to implementing these processes.¹⁵ A national survey found that general dentists consider HRAs important and are willing to incorporate them into their practices, while the barriers to conducting HRAs include time, cost, liability and patients’ willingness.¹⁵ Previous studies have also explored patients’ perspectives on receiving HRAs in dental settings.^12,16–19 Most patients are willing to receive specific HRA from their dentists, such as tobacco¹⁶, substance use¹⁷, blood glucose testing¹², and human immunodeficiency virus (HIV) screening¹⁸. A study conducted in an inner-city dental school clinic found positive patient attitudes toward comprehensive HRA, including blood pressure measurement and blood glucose testing.¹⁹

The current study builds upon prior work by examining patient-reported comfort with discussing six health risk categories: tobacco, alcohol, dietary sugar intake, HIV risks, human papillomavirus (HPV) risks and existing chronic conditions (diabetes, blood pressure, heart disease) with their dental practitioners during routine visits. These health risks and conditions were selected because the United States Preventive Services Task Force has straightforward, primary care A or B grade recommended screenings and these risks are commonly observed among patients.²⁰ In addition, screening for these conditions is considered within the scope of practice for dental practitioners.^21–25 The patients in this study were seen in diverse practices participating in the South Atlantic Region of the United States (US) National Dental Practice-Based Research Network (PBRN).²⁶ In this study, to better understand patient, dentist, and dental practice characteristics associated with HRAs in dental settings, dental patients’ comfort in discussing health risks with their dental practitioners and the number of HRAs received in their dental visit were described. The association between patient, dentist and practice characteristics and two study outcomes, (1) number of risk factors patients were comfortable discussing and (2) number of risk factors assessed in the current dental visit, using multi-level regression models, were examined.

METHODS

Study Design

This cross-sectional survey study was conducted in 2018. A convenience sample of 30 actively licensed dentists were recruited out of 469 dentists in the South Atlantic Region of the US National Dental PBRN who: (1) participated in the Stakeholder Engagement and Multi-Risk Assessment in Dental Care Setting Study,^27,28 and (2) agreed to recruit 30 patients from their practice. All practices completed a brief study administration training session prior to recruiting patients. Between January and March 2018, each dental practice recruited 30 patients receiving care to participate in our study. Patients were eligible if: (1) they were 18 years old or older and (2) their reason for visit was either a routine visit or dental screening visit rather than a restorative treatment visit.

Each participating practice (practitioners and/or office staff) was asked to invite eligible patients to complete patient questionnaires before and immediately after the dental visit until 30 patients per office (900 patients total) were enrolled in the study. Participating practitioners were asked to use a consecutive patient recruitment strategy, adapted to fit practice constraints among individual dentists, to control for selection bias. For example, practices could elect to enroll consecutive eligible patients daily until the target number was reached or enroll consecutive eligible patients on certain days of the week. Practitioners were asked to identify a recruitment schedule and adhere to that schedule. During dental visits, eligible patients were provided with an information sheet that described the study purpose, benefits and risks of participation. If a patient agreed to participate, clinic staff requested the patient to complete a 19-item pre-visit questionnaire while waiting for the dental appointment to begin, and a six-item post-visit questionnaire after completing his or her visit (Appendix A). To ensure patients’ responses remained anonymous to the clinic staff, patients submitted both questionnaires to the study team in a sealed envelope that was dropped into a locked mail box located within the practice. Each patient received a $10 incentive for participating in the study.

The sample size of our study was determined prior to patient recruitment. The required sample size was calculated to provide a narrow enough 95% confidence interval (CI) for the variables (reported as proportions) collected in the patient survey. Conservatively, a proportion of 50% for calculation was used because it requires the largest sample size for building CI. Considering a CI width of 0.07 (± 3.5%), a total of 810 patients were needed based on the Clopper‑Pearson method. To ensure representativeness of the sample, patients from 30 dental offices in the South Atlantic Region of the US National Dental PBRN that were eligible to participate in survey administration were recruited. As a result, it was determined that approximately 30 patients from each of the 30 dental clinics (30 × 30 = 900) would be recruited.

This study was reviewed and approved by the National Dental PBRN Central Institutional Review Board (IRB), based at the University of Alabama at Birmingham, with local context review conducted by the University of Florida IRB. The PBRN Central IRB serves as the single IRB of record for PBRN network studies. The agreement to submit the patient surveys included a waiver of documentation of informed consent per the National Dental PBRN Central IRB regulations.

Survey Questionnaires

The dental patient survey questionnaires were designed by the study team based on the Consolidated Framework for Implementation Research (CFIR).²⁹ The CFIR emphasizes that organizational, stakeholder (practitioner, patient, and payer) and external factors influence the implementation of new interventions. Cognitive testing was performed on the survey instruments using in-depth semi-structured interviews with five patients who were similar to those who would be targeted in the survey. All of the responses from the interviews were analyzed related to the categories of comprehension, retrieval, judgment, and response.³⁰ The structure and types of questions were similar to those used in other cognitive testing situations.³¹

The 19-item pre-visit Questionnaire.

In the pre-visit questionnaire, participants were asked whether they would be comfortable discussing the following six risk factors with their dentist or hygienist (response options: Yes, No, or Not applicable): (1) tobacco use, (2) alcohol use, (3) dietary sugar intake, (4) HIV status and impact to oral health, (5) HPV status and impact to oral health, and (6) existing medical conditions (e.g., diabetes, hypertension, heart disease). An oOpen-ended question was included to allow patients to list the reasons why they were uncomfortable discussing any of the risk factors. Participants were also asked whether they saw a primary medical care provider for a medical check-up or routine care in the last 12 months (response options: Yes, No, or Unsure). If no primary care medical visit took place in the last 12 months, the patients were asked to provide the approximate date of their most recent visit. Lastly, participants’ sociodemographic information, including age, gender, ethnicity, race, type of dental insurance, highest level of education, and zip code of residence was collected.

The six-item post-visit Questionnaire.

In the post-visit questionnaire, participants were asked whether the following HRAs took place during their study dental visit (response options: Yes or No): (1) asked about tobacco use, (2) advised to quit tobacco, (3) asked about alcohol use, (4) discussed dietary sugar intake, (5) discussed sexual risk behaviors, and (6) asked about existing medical conditions.

Variables

Outcomes.

The study outcomes included (1) number of risk factors (range: 0 – 6) patients were comfortable discussing (tobacco use, alcohol use, dietary sugar intake, HIV status and impact to oral health, HPV status and impact to oral health, and existing medical conditions) and (2) number of risk factors (range: 0 – 5) assessed in the current dental visit (tobacco use, alcohol use, dietary sugar intake, sexual risk behaviors, and existing medical conditions).

Patient-related predictors.

Patient-related predictors included age, gender (Female or Male), race/ethnicity (Non-Hispanic white, Non-Hispanic black, Non-Hispanic other, or Hispanic), highest level of education (High school or less or More than high school), dental insurance status (Insured or Uninsured), and primary medical care provider visit in last twelve months (Yes or No). Race/ethnicity, highest level of education, and dental insurance status were variables re-categorized from the original variables for data analysis because of small sample sizes for some of the response levels. According to the International Standard Classification of Education, high school in the United States is classified as upper secondary education.

Dentist and practice-related predictors.

Dentist-related predictors included the dentists’ age, gender (Female or Male), race/ethnicity (Non-Hispanic white or Other than non-Hispanic white), employment status (Full time or Part time), practice location (Florida, Georgia, North Carolina, South Carolina, or Virginia), and practice setting (rural, suburban, urban or inner city), all were obtained from the National Dental PBRN Enrollment Questionnaire. Data on dental practitioner-reported barriers to conducting HRAs were obtained in a practitioner survey.²⁸ The practitioners were asked how often they considered the following barriers to HRAs during dental visits (response options: Never, Rarely, Occasionally, Usually, or Always): (1) Not comfortable with HRA, (2) My patients would be uncomfortable with HRA, and (3) conducting HRAs is outside scope of practice.

Statistical Analysis

First, to describe our study sample, summary statistics including means and frequencies were calculated for the characteristics of the dental patients (Table 1) and the dentists and practices (Table 2). Percentages of patients who were comfortable with HRA for each risk factor (Figure 1) and the percentage of patients who received HRA for each risk factor during the study’s routine dental visit (Figure 2) were also reported. Second, to examine the association between patient, dentist and practice characteristics and the two study outcomes (i.e., number of risk factors patients were comfortable discussing and number of risk factors assessed in the current dental visit), multi-level, multinomial logistic regression models with a practitioner random effect to account for patient clusters were developed.²⁵ Due to small sample sizes, the number of risk factors patients were comfortable discussing was grouped into three or more, two, and one or zero risk factors, and number of risk factors assessed in the current dental visit was grouped into two or more, one, and zero risk factors in the regression analysis. Table 3 shows results from a single multi-level multinomial logistic regression of the number of HRAs patients were comfortable discussing. Table 4 shows results from a single multi-level multinomial logistic regression of the number of HRAs performed. Multi-level logistic regression models were developed to examine the association between patient, dentists and practice characteristics and the receipt of HRA for each risk factor (Supplement Table 1). Multiple testing was controlled using the Bonferroni correction. Variable employment status was excluded from the regression analyses because of small sample size (only two part-time practitioners). All multi-level logistic models were built using the melogit function in STATA 16. All effect estimates were reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Table 1.

Characteristics of dental patients in the study sample.

Characteristic	Frequency or Mean (SD)	Percentage
Age (SD)	51.7 (16.7)
Gender
Male	337	39%
Female	518	61%
Race/Ethnicity
Non-Hispanic white	474	56%
Non-Hispanic black	81	9%
Hispanic	96	11%
Other	190	22%
Education
High school or less	155	18%
More than high school	695	82%
Dental insurance
Insured	574	67%
Uninsured	240	28%
Others	8	1%
Unknown	35	4%
Primary medical care visit in the past year
Yes	742	87%
No	110	13%
Number of HRAs comfortable with
0	35	4%
1	135	16%
2	242	28%
3	201	24%
4	89	10%
5	53	6%
6	102	12%
Number of HRAs received
0	455	53%
1	158	18%
2	68	8%
3	59	7%
4	56	7%
5	61	7%

SD: standard deviation, HRA: health risk assessments

Table 2.

Characteristics of dentists and practices in the study sample.

Characteristic	Frequency or Mean (SD)	Percentage
Age (SD)	52.3 (13.0)
Gender
Male	21	70%
Female	9	30%
Race/Ethnicity
Non-Hispanic White	20	67%
Other or Unknown	10	33%
Employment status
Full-time	28	93%
Part-time	2	7%
Practice location
Florida	20	67%
Georgia	6	20%
North Carolina, South Carolina, Virginia	4	13%
Practice setting
Inner city and Urban	11	37%
Suburban	16	53%
Rural	3	10%

Figure 1.

Patients’ comfort with receiving health risk assessments.

Figure 2.

Patient-reported receipt of health risk assessments during dental visit.

Table 3.

A single, multi-level multinomial logistic regression of the association between number of health risk assessments patients were comfortable discussing and patient, dentist and practice characteristics.

Characteristic	2 vs. 1 or zero HRAs	3 or more vs. 1 or zero HRAs
	OR (95% CI)	OR (95% CI)
Dental patient characteristics
Age	1.06 (0.91–1.23)	1.16 (1.01–1.33)
Gender
Male	Reference	Reference
Female	0.63 (0.38–1.02)	0.38 (0.24–0.60)
Race/Ethnicity
Non-Hispanic White	Reference	Reference
Non-Hispanic Black	1.58 (0.54–4.61)	2.89 (1.06–7.87)
Hispanic	0.98 (0.46–2.12)	1.28 (0.63–2.60)
Other	0.75 (0.41–1.35)	0.91 (0.53–1.56)
Education
HS or less	Reference	Reference
More than HS	1.64 (0.93–2.89)	1.41 (0.85–2.32)
Dental insurance
Insured	Reference	Reference
Uninsured	0.74 (0.43–1.26)	0.94 (0.59–1.52)
Primary medical care visit in the past year
No	Reference	Reference
Yes	0.79 (0.4–1.57)	1.04 (0.54–2.02)
Dentist and practice characteristics
Age	1.10 (0.89–1.36)	0.99 (0.82–1.2)
Gender
Male	Reference	Reference
Female	0.61 (0.34–1.11)	1.61 (0.97–2.69)
Race/Ethnicity
Non-Hispanic White	Reference	Reference
Others	1.71 (0.96–3.04)	1.06 (0.62–1.79)
Practice location
Florida	Reference	Reference
Georgia	1.86(0.98–3.52)	1.12 (0.62–2.01)
North Carolina/South Carolina/Virginia	1.41(0.60–3.31)	0.91 (0.42–1.99)
Practice setting
Inner city/urban	Reference	Reference
Suburban	1.24 (0.73–2.11)	1.92 (1.18–3.14)
Rural	0.77 (0.32–1.88)	1.24 (0.55–2.78)

HRA: health risk assessment, OR: odds ratio, CI: confidence interval, HS: high school

Table 4.

A single, multi-level multinomial logistic regression of the association between number of health risk assessments performed and patient, dentist, practice characteristics and dentist-reported barriers.

Characteristic	1 vs. zero HRAs	2 or more vs. zero HRAs
	OR (95% CI)	OR (95% CI)
Dental patient characteristics
Age	1.11 (0.96–1.29)	1.04 (0.91–1.19)
Gender
Male	Reference	Reference
Female	1.43 (0.92–2.22)	0.62 (0.42–0.90)
Race/Ethnicity
Non-Hispanic White	Reference	Reference
Non-Hispanic Black	1.29 (0.53–3.14)	1.66 (0.80–3.45)
Hispanic	1.31 (0.61–2.84)	1.72 (0.90–3.29)
Other	1.09 (0.61–1.96)	1.44 (0.87–2.39)
Education
HS or less	Reference	Reference
More than HS	0.96 (0.55–1.66)	0.68 (0.42–1.10)
Dental insurance
Insured	Reference	Reference
Uninsured	0.69 (0.41–1.17)	1.12 (0.70–1.78)
Primary medical care visit in the past year
No	Reference	Reference
Yes	0.57 (0.30–1.09)	0.88 (0.47–1.64)
Dentist and practice characteristics
Age	0.97 (0.73–1.27)	0.70 (0.54–0.90)
Gender
Male	Reference	Reference
Female	0.99 (0.48–2.04)	1.19 (0.65–2.20)
Race/Ethnicity
Non-Hispanic White	Reference	Reference
Others	0.73 (0.29–1.83)	2.74 (1.16–6.45)
Practice location
Florida	Reference	Reference
Georgia	1.15 (0.50–2.65)	0.74 (0.36–1.52)
North Carolina/South Carolina/Virginia	0.85 (0.32–2.29)	1.48 (0.61–3.60)
Practice setting
Inner city/urban	Reference	Reference
Suburban	0.62 (0.27–1.41)	0.98 (0.50–1.90)
Rural	0.66 (0.26–1.66)	0.94 (0.36–2.45)
Dentist-reported barriers to conducting HRAs
Personally not comfortable screening for multiple health risks
Never	Reference	Reference
Occasionally	0.60 (0.19–1.86)	3.90 (1.32–11.7)
Usually/always	0.52 (0.12–2.15)	1.53 (0.40–5.77)
My patients will be uncomfortable
Never	Reference	Reference
Occasionally	2.93 (1.04–8.29)	0.37 (0.14–0.94)
Usually/always	1.90 (0.53–6.78)	0.86 (0.31–2.42)
Conducting HRAs is beyond my scope of practice
Never	Reference	Reference
Occasionally	1.00 (0.45–2.23)	0.46 (0.22–0.95)
Usually/always	0.67 (0.20–2.20)	0.33 (0.13–0.81)

HRA: health risk assessment; OR: odds ratio; CI: confidence interval; HS: high school

RESULTS

Dental patient, dentist, and practice characteristics

A total of 857 (95%) of the 900 patients submitted pre-visit and post-visit questionnaires (Table 1). The mean patient age was 51.7 years with a standard deviation (SD) of 16.7 years. The majority of patients were female (61%), non-Hispanic white (56%), of more than high school education (82%), and with dental insurance (67%). The majority indicated they visited a primary medical care provider in the previous 12 months (87%).

Dentists’ average age was 52.3 years with an SD of 13.0 years (Table 2). The majority of dentists were male (70%), non-Hispanic white (67%), full-time (93%), in Florida (67%), and in inner city/urban (37%) or suburban (53%) areas.

Patient comfort with and receipt of health risk assessments

As seen in Table 1, only 4% of the patients were not comfortable with HRA on any of the risk factors, and a little over half of the patients were comfortable with HRA on 3 or more risk factors. In contrast, 53% of the patients indicated they did not receive any HRA in the current dental visit. About 29% of the patients indicated they received an HRA on 2 or more risk factors.

Figure 1 shows the number and percentage of patients who were comfortable with receiving HRA for each risk factor during dental visits. Over 90 percent of the patients were comfortable discussing dietary sugar intake (93%) during their dental visits. In contrast, only 19% and 21% of the patients were comfortable discussing HIV and HPV risk with their dentist, respectively. Figure 2 shows the number and percentage of patients who received an HRA on each risk factor during the current dental visit. Patients were most likely to report being asked about chronic conditions (35%), tobacco use (28%), dietary sugars (24%), and alcohol use (21%). A small percentage (8%) of patients reported being asked about sexual risk behaviors during their visit.

Association between number of HRAs patients’ comfort with and patient, dentist and practice characteristics

As seen in Table 3, accounting for the other predictors, older patients were more likely to be comfortable with receiving HRA for three or more risk factors (OR = 1.16, 95% CI: 1.01 – 1.33) compared to younger patients. Female patients were less likely to be comfortable with receiving HRA for three or more risk factors (OR = 0.38, 95% CI: 0.24 – 0.60) compared to male patients. Compared to those who attended inner city or urban dental practices, patients who attended suburban dental practices were more likely to be comfortable with receiving HRA for three or more risk factors (OR = 1.92, 95% CI: 1.18 – 3.14), but no difference was observed for patients who attended rural dental practices (OR = 1.24, 95% CI: 0.55 – 2.78). No significant differences in the patient, dentist and practice characteristics were observed between patients who were comfortable with receiving HRA for two versus one or zero risk factors.

Association between number of HRAs performed and patient, dentist, practice characteristics and dentist-reported barriers

As seen in Table 4, accounting for the other predictors, female patients were less likely to receive HRA for two or more risk factors (OR = 0.62, 95% CI: 0.42 – 0.90) compared to male patients. Older dentists were less likely to provide HRA for two or more risk factors compared to younger dentists (OR = 0.96, 95% CI: 0.94 – 0.99). Compared to non-Hispanic white dentists, those who were of a different race/ethnicity were more likely to provide HRA for two or more risk factors (OR = 2.74, 95% CI: 1.16 – 6.45). Dentists who personally felt occasional discomfort in conducting multiple HRAs were more likely to provide HRA for two or more risk factors compared to dentists who felt no discomfort in doing so (OR = 3.90, 95% CI: 1.32 – 11.7). Compared to dentists who were never concerned about patient discomfort with HRAs, those who were occasionally concerned were less likely to provide HRA for two or more risk factors (OR = 0.37, 95% CI: 0.14 – 0.94), but more likely provide HRA for one risk factor (OR = 2.93, 95% CI: 1.04 – 8.29). Compared to dentists who never felt that conducting HRAs was beyond their scope of practice, those who occasionally (OR = 0.46, 95% CI: 0.22 – 0.95) or usually/always (OR = 0.33, 95% CI: 0.13 – 0.81) felt that conducting HRAs was beyond the scope were less likely to provide HRA for two or more risk factors. The association between conducting HRA for each risk factor and patient, dentist, practice characteristics and dentist-reported barriers was provided in the Supplement Table 1.

DISCUSSION

In the study sample of dental patients, only a small percentage (4%) of patients expressed discomfort in discussing health risks and chronic conditions with their dental practitioners. Yet, more than half (53%) of the patients reported that they did not receive any HRAs during their appointment for a regular checkup or dental screening, followed by 18% who received only one HRA. It is noteworthy that receiving HRAs was significantly associated with both patient and dentist factors, with female patients being less likely to receive HRAs for more than one health risk as well as for particular types of risks, including tobacco and alcohol use, relative to men. Further, dentists were significantly less likely to provide HRA for two or more health risks if they believed that their patients would not be comfortable being asked these HRA questions or if they perceived such assessment to be beyond their practice scope. Yet, those who reported occasional personal discomfort with HRA were more likely to provide HRA for more risks.

Multiple studies in medical primary care settings find variations in receipt of HRA based on patient and physician characteristics.^32,33 Possible contributing factors cited in these studies include high workload, personal beliefs about patient behaviors, and the belief that universal HRA is inefficient and could limit time for care delivery related to the patients’ presenting problems. For example, one study focused on alcohol screening in primary care revealed that some medical providers believed adults over 70 had less risk for alcohol abuse and therefore did not need to be screened.³⁴ It is possible that dental practitioners conduct targeted HRA based on their prior knowledge of the patient or general beliefs about the health risks and behaviors of patients based on their age or other sociodemographic characteristics. The finding that dentists who were personally occasionally uncomfortable with HRA provide HRA for more health risks may seem counter-intuitive. However, it is possible that because the practitioners who provided HRA for more risks (e.g., alcohol use), had greater opportunity to experience discomfort with potentially sensitive topics than those conducting fewer assessments.

Overall, the study findings point to missed opportunities to screen patients for health risk behaviors and chronic conditions. Multiple studies have identified gaps in conducting recommended HRA in medical primary care settings.^35–38 Other studies have examined dental practitioners’ views on the feasibility of conducting HRA in dental settings to increase screening opportunities.^39,40 Studies focused on enhancing HRA in both medical primary care and dental settings address the importance of systematically using screening tools, implementing HRA within the context of clinic workflow, and using clinical champions and learning collaboratives.⁴¹ These strategies are robust and feasible to facilitate practice change and the adoption of screening interventions.²⁹ Further, the systematic adoption of screening tools should help reduce variability in HRA based on patient gender, race and ethnicity.

The current study has several limitations. First, patients were not asked how many years they had been receiving care by their particular dentist. It is possible that patients were selectively asked about their health risks because the dental practice had prior knowledge of their health history. Nonetheless, regular assessments and reassessments are important in the event that a patient’s health status has changed. Second, this study recruited a convenient sample of dentists in the PBRN and their patients who may not accurately represent the intended population. However, prior research has documented that patterns of diagnosis and treatment from network general dentists are similar to those from non-network general dentists.^42–45 Third, although survey data were collected using the US National PBRN questionnaires, the reliability and validity of the questions were not assessed in this study. Fourth, patients’ comfort with receiving HRA was assessed using a binary (yes or no) response format. Therefore, it was not possible to evaluate patients’ degree of comfort with the HRA. Lastly, patients’ comfort with HRAs was evaluated independent of their HRAs received.

Conclusion

Patients reported greater comfort in participating in HRA in dental offices than the practitioners perceived to be the case. Further, dental practitioners provided HRA differentially based on certain patient characteristics. These results suggest that interventions should focus on reducing dental practitioner perception that conducting HRAs is beyond their scope of practice and that dental patients are uncomfortable receiving HRAs during dental visits. Additionally, future research should focus on providing standardized tools to help practitioners systematically assess patients for common conditions and the impact of linking HRAs to reimbursement for new patient and routine screening visits.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, YG, upon reasonable request.