Determinants of Dentist–Patient Relationships: A Scoping Review

Abstract

Objectives

The dentist–patient relationship (DPR) is considered to be a key element in dental clinical settings. This scoping review aimed to examine the extent of previous research on DPR, focussing on its determinants for the reification of the construct.

Methods

This research was directed by the guidance for systematic scoping reviews from the Joanna Briggs Institute. The inclusion/exclusion criteria were based on participants of general adults and dentists, the concept of determinants of DPR, and the context of dental health care encounters. A literature search was performed in 6 major electronic databases in July 2023. Key information from included articles was extracted to chart the results, mainly to identify the determinants of DPR. Each determinant of DPR was classified according to the conceptual model of DPR.

Results

A total of 1727 records were initially identified, and 16 articles were included in the review. Nine studies used a quantitative method and 7 were nonempirical articles. All but 2 articles were from the perspective of patients. Factors were grouped into 6 main domains: dentist, patient, society/environment, clinical structure, clinical process, and outcome. Amongst the 6 domains of DPR, most determining factors were related to the clinical process. "Communication” was most frequently counted, at 8 times, followed by “trust” (frequency, 6). At the patient level, “dental fear/anxiety” was frequently used to measure DPR.

Conclusions

Previous literature about DPR indicated a few common and dentistry-specific determinants from the patient perspective. Further studies are encouraged to develop a more comprehensive framework and evaluation scale of DPR.

Introduction

Either as face-to-face visits or virtual online consultations, clinical encounters are considered to be a key element in health care services.¹ At the heart of clinical encounters are provider–patient relationships,² reflecting dynamic social relations in medical contexts.³ The optimal delivery of health care services is supported by therapeutic relationships between providers and patients, ensuring quality of care.^1,2 The same notion seems applicable in dentistry, as it is a health and medical discipline, by simply replacing “physicians” with “dentists” as a profession in the relationship.⁴ It can be claimed that the dentist–patient relationship (DPR) “covers (nearly) all aspects of care” and a favourable DPR “increases the quality of care and patient satisfaction.”⁵

The acknowledged justification, however, has been primarily dependent on either normative arguments^6,7 or extrapolation from the generic medical setting.⁸ Empirical analyses are advised to measure, establish, and benefit from better DPR beyond simply suggesting abstract values as ethical imperatives.^7,8 Also, the interchangeability of health care “providers” in the relationship with patients needs to be refined for the distinctive nature which clinical dentistry inherently holds.⁸ In other words, studies about DPR should focus on dental contexts with more robust empirical evidence, despite its initial grounding in the medical frame of reference with didactic lessons.

For that matter, a practical starting point for further study may be how to operationalise the construct of DPR with regards to its multidimensionality and compartmentalisation.⁶ Some of the relevant concepts comprising DPR have been suggested by theoretical and conceptual models and include but are not limited to communication, trust, satisfaction, ethics, control, and decision-making in clinical encounters.^5,6,9,10 However, there remains a gap in identifying determinants or components of DPR from the less consistent structure of operational definition.⁶ As the doctor–patient relationship has been “loosely defined” and thematically found with components in the framework from the previous literature, the main search terms were focussed on determinants rather than definitions of it.¹¹ A more definitive framework with measurable psychometric variables can help explore therapeutic DPR in a comprehensive manner.

Scoping reviews are to “scope out” the extent and nature of the research topic from previous literature as a preliminary outline.¹² In particular, scoping reviews are useful to identify parameters of a certain domain in advance of more in-depth analyses such as systematic reviews.^13,14 Based on the indication of scoping reviews—for clarification of key concepts in the literature¹⁴—the format appears to be appropriate to our interests in the topic. The gap in the research about DPR detected earlier is expected to be filled by mapping potential determinants of DPR from the terrain of previous studies.

Derived from the rationale of DPR and a gap in current knowledge, this scoping review aimed to examine the extent of previous research into DPR, with a focus on its determinants for reification of the construct. The aim was pursued by asking two research questions: What are determinants of the relationship between dentists and patients drawn from previous literature? What methodological approaches has previous literature taken to determine the dentist–patient relationship? Answers to those questions can serve as indicators for developing frameworks and measuring instruments for DPR.

Material and methods

Protocol and reviewers

This review followed the guidance and manual for systematic scoping reviews from the Joanna Briggs Institute.^12,13 As requisites for rigourous methods of scoping reviews,¹² 2 regular reviewers (HC and RJK) participated in the entire process of review. The a priori protocol of methods including screening and eligibility criteria was developed and specified in advance of conducting the review.¹³ No critical appraisal for assessing the risk of bias was performed for the aim of the article in the format of a scoping review.12, 13, 14

Inclusion/exclusion criteria

The inclusion/exclusion criteria were primarily based on the framework of participants, concept, and context in the guidance.^12,13 Studies were considered eligible for inclusion in the review if they involved participants of general adults and general dentists with the concept of determinants/components of DPR in the context of dental health care service or encounters. Other inclusion criteria were as follows: (a) peer-reviewed publications to secure the minimum quality for a dearth of critical appraisal; (b) papers published from 2000 onwards, considering the time period of attention shed on “doctor–patient relationship” in earnest⁶; (c) papers written in the English language for the detailed data extraction; (d) no restrictions on the type of papers or geographical or cultural limits for the universality of clinical dental settings.⁵ Exclusion criteria were as follows: (a) studies implemented with participants of a specific group; (b) studies of a certain single component of DPR; and/or (c) studies in specific settings of dental contexts, for example, studies in patients with oral cancer, communication skill development for dental students, and/or proxy relationships between parents/guardians of older patients and dentists. Particularly, we ruled out studies with young participants (aged 18 years or younger) as the findings from general adults are inapplicable to paedodontic contexts for their inherently different nature.¹⁵ Studies were also excluded if they (d) were about comparison or evaluation of specific dental treatments or (e) addressed DPR with a fleeting comment or brief allusion rather than in a comprehensive approach. In addition, (f) grey literature, such as book reviews and newspaper articles, was excluded from our results as being neither peer-reviewed for quality nor bibliographic data available for the reproducibility of literature search. Tabulated inclusion/exclusion criteria are summarised for clarification in the supplementary material (Table S1).

Search strategy and study selection

Six electronic databases (PubMed, Embase, Scopus, Web of Science, Medline, PsychINFO) were searched to identify relevant records using medical subject headings, search terms, and their plausible variants in July 2023. A detailed search strategy in accordance with each database is available in the supplementary material (Table S2). All records identified through the online search were initially screened with titles and abstracts after duplicates were removed. A few missing records from the electronic search were also added by citation chaining and hand-searching, if found relevant to the review questions. Two reviewers (HC and RJK) jointly screened the first 30 articles retrieved, in the order of publication year and independently reviewed the remaining records in parallel. The full text of filtered articles was also independently assessed for final inclusion eligibility in the review. A third reviewer (YS) was invited to resolve any disagreements over the course of the entire process.

Data extraction

Key information from included articles was extracted to “chart the results.”¹² The common items of extraction from all articles were author(s), publication year, study aim, study type, perspective of DPR, and determinants of DPR. In addition, the context of the article was sought from nonempirical papers, whereas empirical studies were reported with the main findings of the study. To answer the second research question, information of study design, study samples, data collection, scale/measurement, number of items in the measurement scale, and outcome were extracted from empirical articles. Potential determinants were identified through the process of data extraction, mainly from dimensions of psychometric scales in empirical studies and thematic concepts in nonempirical papers. To structuralise determinants using the framework, factors of DPR identified were classified into the conceptual model of dentist–patient encounters in clinical settings and counted numerically, reflecting their frequent appearance for DPR. Each item was extracted independently by 2 reviewers (HC and RJK) and validated in shifts under the supervision of the third reviewer (YS).

Conceptual model of DPR as a theoretical framework

To analyse the determinants of DPR in a structured framework, we used a conceptual model that was derived from the partial modification of “a model for encounters in dentistry.”⁹ The original model was built upon a systematic theory for dentist–patient communication in a dental context and has been widely adopted for the research of DPR.^7,16,17 For this review, the idea of contextual influencers,⁶ which was introduced in DPR previously,^8,15 was embraced for the expansion of the clinical structural factor to analyse existing determinants in a comprehensive manner. In accordance with thematic analysis, key elements and determinants of DPR are categorised in the most relevant domain amongst 6 drawn from the conceptual model: dentist, patient, society/environment, clinical structure, clinical process, and outcome (Figure 2).

Fig. 2.

Diagram of determinants in dentist–patient relationships.

Adapted from Sondell et al, 1997⁹ and Hoff et al, 2017.⁶

Results

A total of 1727 records were initially identified, and 16 articles were included in the scoping review after screening and eligibility assessment. Figure 1 shows the review process in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.¹⁸ The criteria most frequently applied to the screening process were studies about child dental patients (n = 106), dental students and/or dental education curricula (n = 88), orthodontic treatment (n = 48), and smoking cessation in dental settings (n = 35). Reasons for excluding 19 papers from eligibility after full-text assessment are provided in Table S3 (supplementary material). The number of nonempirical papers was 7, and 9 empirical articles were included. For nonempirical articles, 4 papers^16,19, 20, 21 were written by the same author in the same year under the same format, so they were considered a series of a single project (Table 1).

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for the scoping review process.

Table 1.

Summary of all papers included in the scoping review.

Author (year)	Aim	Type	Context/main finding	Perspective	Determinants of DPR
Mataki (2000)7	Review patients’ satisfaction regarding the communication with dentists	Narrative review	Behavioural dentistry with a focus on dentists’ communicative styles	Patients	Communicative style (involvement and dominance), dental anxiety, first- or repeat-visit, patients’ education, patients’ sex and age
Coolidge et al (2005)24	Examine psychometric properties of the revised Dental Beliefs Survey	Cross-sectional empirical study	Revised Dental Beliefs Survey can be useful to measure patients’ perceptions of dental practices in both clinical and nonclinical settings	Patients	Subscales of revised Dental Beliefs Survey: professionalism, communication, lack of control, trust
Yamalik (2005)16,19,20,21	Examine diverse dimensions of the interaction between dentist–patient relationship and quality care	Commentary	A series of articles initiated as a dental practice committee project	Patients	Trust, communication, professional information for providing informed consent, biobehavioural awareness
Brennan et al (2006)23	Investigate dentist preferences for patients with regard to characteristics of dentists and services provided	Cross-sectional empirical study	Dentist preferences for patients may influence the practice of dental services provided	Dentists	Dimensions of Dentist Preferences for Patients Scale: treatment adherence, social interactiveness, personal adaptability, enabling characteristics
Abrahamsson et al (2006)25	Explore the psychometric properties of a Swedish version of the revised Dental Beliefs Survey and its predictive value for dental fear	Cross-sectional empirical study	Subdimensions of the revised Dental Beliefs Survey were significant predictors of dental fear; despite its reliable and valid psychometric properties, its factor structure needs to be investigated further	Patients	Dimensions of revised Dental Beliefs Survey: ethics, communication, control, trust
Abrahamsson et al (2009)26	Evaluate the factor structure of the revised Dental Beliefs Survey	Cross-sectional empirical study	Revised Dental Beliefs Survey may need to be interpreted as an overall construct of “dental beliefs” rather than multidimensional instruments	Patients	Factors of revised Dental Beliefs Survey: ethics, belittlement, communication/empathy, control/anxiety
Griffith et al (2013)22	Explain the role of a consumer's trust and commitment in the consumer–dental provider relationship	Narrative review	The commitment-trust theory of relationship in health marketing	Patients and dentists	-Patients: Consumer's trust and commitment to the dental professional -Dentists: Professional organisations and regulatory agencies
Muirhead et al (2014)28	Assess the association between oral health–related quality of life and dentist–patient relationships	Cross-sectional empirical study	Older people's unmet dental needs and lack of confidence/trust in their dentists were associated with their poor oral health–related quality of life	Patients	Perceived dental needs, decision-making involvement, time for dental discussion, respect/dignity, confidence/trust
Jones et al (2014)17	Identify key variables in the dentist–patient relationship and explore the application of empathy to improve it	Literature review	A general review for key variables in Dental Beliefs Survey and detailed application of empathy found previously	Patients	Communication, empathy
Kheir et al (2019)29	Examine the effects of the dentist–patient interactions on young adults’ dental anxiety	Cross-sectional empirical study	The patient–dentist relationship is significantly associated with dental anxiety in young adult Sudanese	Patients	Communication, respect/dignity, confidence, negative responses, listening to patients, time to discuss, involvement in decision, obtaining answers
Song et al (2020)15	Investigate whether dentist–patient relationships are positively associated with oral health–related quality of life	Cross-sectional empirical study	Favourable Dental Beliefs Survey variables were associated with better oral health–related quality of life after adjusting for putative confounders	Patients	Trust in dentists, satisfaction with dental care, dental fear
Yuan et al (2020)30	Predict dental attendance behaviours using person-centred and socioeconomic position factors	Cross-sectional empirical study	Dentist's communication, patient's trust, shame, and dental anxiety have a complex relationship across different categories of patients	Patients	Communication, trust, anxiety, patient's feelings of shame about teeth, patient's socioeconomic position
Yong et al (2021)27	Determine the satisfaction with the dentist–patient interaction and factors associated with patient satisfaction	Cross-sectional empirical study	Dentist–patient interaction was found to be influenced by the characteristics of the dentist	Patients	Distress relief; rapport/confidence; interaction outcome; dentist age, gender, and years of service

DPR, dentist–patient relationship.

Characteristics of included studies

Key information extracted from all papers in this review is summarised in Table 1. No specific time trends or geographical/cultural patterns across the selected were observed. All articles included were from patients’ perspective of DPR, except 2 that were from the viewpoint of dentists.^22,23 One paper was from the context of health marketing/management,²² one from health psychology,¹⁷ and the others from clinical dental contexts. Determinants of DPR were generally suggested in narrative from nonempirical papers and not distinctively itemised due to the nature of descriptive reviews and opinions. All empirical studies adopted a cross-sectional design for the data from either self-completed or interviewer-administered questionnaires.

Methodological approaches

All nonempirical papers were either narrative/literature reviews or commentaries with no systematic reviews included, which have few findings about methodological approaches. The methods used by empirical studies in the scoping review can be found in Table 2. Most empirical studies used a primary data collection method from study samples. Only one study used UK Adult Dental Health Survey data to analyse dental attendance behaviours of adults. Amongst empirical articles, 5 studies explored psychometric properties of multi-item scales,23, 24, 25, 26, 27 and 3 of them investigated the same scale: the Revised Dental Beliefs Survey (R-DBS).24, 25, 26 Two studies introduced a set of single dichotomous questions (5 items²⁸ and 8 items²⁹) to represent DPR. Following the design of empirical analyses, determinants of DPR were presented as dimensions/factors of psychometric scales,23, 24, 25, 26 key words of single questions,^28,29 or an assortment of scales in DPR block.¹⁵ Outcome variables in empirical studies were dental anxiety in 3 articles,^24,25,29 oral health–related quality of life in 2 articles,^15,28 dental service rates from an article on dentists’ perspectives in 1 article,²³ dental attendance behaviours in 1 article,³⁰ and patient satisfaction in 1 article.²⁷ The main findings were, in general, possible associations between determinants of DPR as predictors and outcome variables.

Table 2.

Summary of methods used by empirical studies included in the scoping review.

Author (year)	Study design	Study samples	Data collection	Scale/measurement	No. of items	Outcome
Coolidge et al (2005)24	Cross-sectional design from directly distributed self-completed questionnaires	Study I with 108 college students and Study II with 141 adult patients of dental injection phobia, both in the US	Primary	Revised Dental Belief Survey (R-DBS) (to assess patients’ perception about dental encounters)	28	Dental control and anxiety
Brennan et al (2006)23	Cross-sectional design from mailed self-completed questionnaires	1202 dentists in Australian private general practice	Primary	Dentist Preferences for Patients Scale (to assess dentist perceptions of their patients)	37	Dental service rate
Abrahamsson et al (2006)25	Cross-sectional design from mailed or directly distributed self-completed questionnaires	710 Swedish adults (240 students, 200 general dental patients, 170 periodontal patients, 100 patients from the dental-fear treatment waiting list)	Primary	Revised Dental Beliefs Survey (R-DBS) (to assess interpersonal relationship in dental encounters)	28	Dental anxiety scale
Abrahamsson et al (2009)26	Cross-sectional design from directly distributed self-completed questionnaires	370 regular dental patients in Sweden (200 general dental patients, 170 periodontal patients)	Primary	Revised Dental Beliefs Survey (R-DBS) (to assess interpersonal relationship in dental encounters)	28	-
Muirhead et al (2014)28	Cross-sectional design from an interviewer-administered questionnaire and an oral examination	1270 households with older people aged 65 years and older in the UK	Primary	Five dichotomous questions about dentist–patient relationships	5	Oral Health Impact Profile-14
Kheir et al (2019)29	Cross-sectional design from interviewer-administered questionnaires	864 Sudanese young adults aged 18–24 years	Primary	Eight dichotomous questions about patient–dentist interactions	8	Dental Anxiety Scale
Song et al (2020)15	Cross-sectional design from mailed self-completed questionnaires	12,254 Australian adults	Primary	Dentist Trust Scale (DTS), Dental Care Satisfaction (DCS), dental fear	DTS = 11 DCS = 9 Dental fear = 1	Oral Health Impact Profile-14
Yuan et al (2020)30	Cross-sectional design from structured interview	11,172 United Kingdom adults	Secondary (UK Adult Dental Health Survey)	Modified dental anxiety scale, 4 dichotomous questions about trust, 3 trichotomy questions about communication, 2 question from Oral Health Impact Profile-14 about shame of oral status	Dental anxiety = 5 Trust =4 Communication = 3 Shame =2	Dental attendance behaviours
Yong et al (2021)27	Cross-sectional design from directly distributed self-completed questionnaires	229 patients attended outpatient dental clinic in Malaysia	Primary	Skala Kepuasan Interaksi Perubatan-11 (SKIP-11)	11	Patient satisfaction

Determinants of DPR

A total of 39 potential determinants were identified, of which 15 were recorded more than once. All DPR determinants were distributed in 6 domains of the modified model for encounters in dentistry (Table 3). The 6 domains were as follows: dentist, patient, society/environment, clinical structure, clinical process, and outcome (Figure 2). In terms of dentist-related factors, 5 items were found: age, gender, total service year, professionalism, and ethics. Ethics was the only indicator mentioned more than once, but articles describing ethics were written by a single author.^25,26 In addition, 13 determinants were included in the patient domain, and fear/anxiety was the most frequently addressed in the domain, discussed in 4 articles.^7,26,27,30 There were few papers linking patients’ sociodemographic factors (age, gender, ethnicity, education, occupation, income, and marriage) to DPR determinants.^7,25,27,30 A study from the dentists’ perspective included patients’ personality components as predictors of DPR.²³ A small number of factors were classified into both the society/environment domain and the clinical structure domain. Only one article connected society/environment components (professional organisation, regulatory agency) to DPR in the health marketing context.²² Time for dental discussion was the only factor included in the clinical structure domain.^28,29

Table 3.

Summary of determinants of dentist–patient relationship in various domains.

Domain	Determinants		No. of studies	Author (year)
Dentists	Age		1	Yong et al (2021)
	Gender		1	Yong et al (2021)
	Total service year		1	Yong et al (2021)
	Professionalism		1	Coolidge et al (2005)
	Ethics		2	Abrahamsson et al (2006, 2009)
Patients	Age		3	Mataki (2002), Abrahamsson et al (2006), Yong et al (2021)
	Gender		3	Mataki (2000), Abrahamsson et al (2006), Yong et al (2021)
	Ethnicity		1	Yong et al (2021)
	Education		2	Mataki (2002), Yong et al (2021)
	Occupation		2	Yuan et al (2020), Yong et al (2021)
	Income		1	Yong et al (2021)
	Marriage		1	Yong et al (2021)
	Care experience		2	Mataki (2000), Yong et al (2021)
	Fear/anxiety		4	Mataki (2000), Abrahamsson et al (2009), Muirhead et al (2014), Yuan et al (2020)
	Oral status		1	Yuan et al (2020)
	Personality	Social interactiveness	1	Brennan et al (2006)
		Enabling characteristics	1	Brennan et al (2006)
		Personal adaptability	1	Brennan et al (2006)
Society Environment	Professional organisation		1	Griffith et al (2013)
	Regulatory agency		1	Griffith et al (2013)
Clinical Structure	Time for dental discussion		2	Muirhead et al (2014), Kheir et al (2019)
Clinical Process	Perceived dental needs		1	Muirhead et al (2014)
	Listening to patients		1	Kheir et al (2019)
	Obtaining answers		1	Kheir et al (2019)
	Decision-making involvement		2	Muirhead et al (2014), Kheir et al (2019)
	Communication		8	Mataki (2000), Coolidge et al (2005), Yamalik (2005), Abrahamsson et al (2006, 2009), Jones et al (2014), Kheir et al (2019), Yuan et al (2020)
	Empathy		2	Abrahamsson et al (2009), Jones et al (2014)
	Control		3	Coolidge et al (2005), Abrahamsson et al (2006, 2009)
	Trust		6	Coolidge et al (2005), Yamalik (2005), Abrahamsson et al (2006), Griffith et al (2013), Song et al (2020), Yong et al (2021)
	Confidence		3	Muirhead et al (2014), Kheir et al (2019), Yong et al (2021)
	Respect/dignity		2	Muirhead et al (2014), Kheir et al (2019)
	Belittlement		1	Abrahamsson et al (2009)
	Distress relief		1	Yong et al (2021)
Outcome	Treatment adherence		1	Brennan et al (2006)
	Biobehavioral awareness		1	Yamalik (2005)
	Negative response		1	Kheir et al (2019)
	Satisfaction with dental care		1	Song et al (2020)
	Interaction outcome		1	Yong et al (2021)
	Commitment		1	Griffith et al (2013)

All literature included in the review, except for a single paper,²³ described DPR in terms of clinical process. Twelve possible items were listed, and communication was most frequently counted, at 8 times, followed by trust, at 6 times. The 2 determinants of control and confidence ranked third (at 3 times), and more even distributions were found for empathy, decision-making involvement, and respect/dignity, each counted twice. Finally, 6 separate articles reported different determinants of DPR in terms of outcome domain: treatment adherence, biobehavioural awareness, negative response, satisfaction with dental care, interaction outcome, and commitment. In most cases, studies focussed more on patient-reported outcomes and patients’ behavioural changes than on clinical treatment outcome when determining DPR. Overall, most literature concentrated on clinical process and patient factors to evaluate DPR, whereas a relatively small number focussed on society/environment and clinical structure domain.

Discussion

This article examined previous research about DPR to identify its determinants for operationalisation of the construct. The format and a priori criteria of a scoping review could find relevant records and single out papers eligible for answering the review questions. Key information was extracted from both nonempirical and empirical studies included. A few determinants representing DPR were observed from the published literature and analysed with a modified conceptual model to determine their potential as structural components of DPR for further study.

Conceptual model for encounters in dentistry

Before interpreting results for determinants of DPR, a series of consistently contiguous concepts underlying the relationship between provider and patient appears. They are the biopsychosocial model of health, patient-reported outcomes, and patient-centred care. The background of DPR relies heavily on the transitional paradigm of health and health care across all the articles in the review. As opposed to the biomedical model, the biopsychosocial model of health takes into account “not only the biological criteria, but also the social, cultural, and psychological variables of disease causation.”³¹ Thus, the ultimate criteria of health from the perspective of patients might be “psychosocial, even when the complaint is physical.”³² The model constitutes a fundamental basis for the physician–patient relationship¹ with patient-reported outcomes and patient-centred care. Both concepts with patients’ values and perspective being at the centre of health care play a key role in outlining the conceptual model of interaction in clinical settings.^1,10,33 They can also justify the primary approach in this review from the patients’ perspective by balancing clinicians’ dominant power in health care encounters.^34,35

Domains that constitute DPR

In the conceptual model as a framework, DPR is composed of 6 domains: dentist, patient, society/environment, clinical setting, clinical process, and outcome. Each determinant is divided into these 6 domains (Table 3). Most papers in the review examined factors that arise during the clinical treatment process in the dental context. Within the clinical treatment process, when compared to care- and treatment-related factors, determinants related to communication were analysed most. Although the majority of dental procedures are performed in the mouth, which inherently poses communication difficulties,⁹ these brief moments of communication play a major role in DPR.

Meanwhile, because most papers examined DPR from the patient's perspective, most determinants were classified as patient factors. This result reflects the transition from a biomedical model, in which providers played a dominant role in the past, to a biopsychosocial model, in which patients and dentists are on equal footing. However, to investigate DPR comprehensively, studies from the dentist's perspective are also needed to strike a balance. The same is advised for society/environment and clinical structure domain, as only one article²² proposed that organisation of dentists and regulatory agencies can affect DPR. A single study relates clinical structure factor and dental fear/anxiety,²⁹ but it does not extend its view to link clinical structure to DPR.

Individual determinants of DPR

It was expected that “communication” was dealt with most frequently, as it has been used all but interchangeably with “relationship” in the context of medical^1,36 and dental encounters.^7,9 Therapeutic communication is considered critical to translate patient-centred care for assessing quality of care.^36,37 Communication in health care covers an extensive framework of DPR, not only delivering/exchanging health information but also inducing informed consent through shared decision-making^36,38 and relief of dental fear/anxiety.³⁹ In particular, the establishment of “trust,” the second most frequent determinant of DPR, is closely associated with communication in clinical settings.^8,40 Even the core element of interpersonal trust in health care, “the acceptance of a vulnerable situation,”⁴⁰ resonates more decisively amongst dental patients given the invasive and anxiety-inducing nature of clinical dentistry.^8,39 Although the verbatim term was not identified, “autonomy” emerges from the third-place ranking of “decision-making involvement” and fourth-place ranking of “control” as a consolidated determinant. The importance of patients’ autonomy has been sufficiently acknowledged by delineating normative models of the physician–patient relationship.^1,10,33

When comparing determinants of DPR with those in a conceptual model from medical contexts,⁶ the majority are in common with similarities of feature for extrapolation. The 2 most frequent determinants, “communication” and “trust,” were found in the physician–patient relationship together with “autonomy” collectively representing the aforementioned runners-up.⁶ In addition, some less frequently counted determinants were shared: “empathy,” “time,” and “respect.”⁶ However, the contextual difference reported “dental fear/anxiety” as a DPR-specific determinant. Fear of dental treatment is known to influence patients’ attitudes towards dentists and dental visiting patterns, eventually leading to unfavourable oral health outcomes.^7,41 Interestingly, “regulation” as a force in medical settings⁶ was discovered in DPR only from dentists’ perspective as professional environments.²²

Some determinants of DPR were also claimed to be outcomes of dental service. “Dental fear/anxiety” as a determinant^7,15 was also considered to be an outcome by the establishment of better DPR in a negative manner.^17,21,29 Particularly, articles about the scale of R-DBS adopted the Dental Anxiety Scale as a correlate for its validity and factor structure.^24,25 That can be ascribed to the purpose of developing the R-DBS for the assessment of fearful patients’ perceptions and attitudes towards dentists.24, 25, 26 Considering the distinctive nature of dental clinical settings, the hypothesis that dental fear/anxiety can play both roles of a causative predictor and a consequential outcome with regards to the objective and design of research about DPR is possibly true. “Satisfaction” and “adherence” were also found to be both determinants^15,23 and outcomes.^6,17 Further clarification of conceptual definitions and empirical study design is advised to better understand the duality of such determinants/outcomes of DPR.

Limitations and strengths

The limitations of this article are mainly derived from the format of methodology, as a scoping review. The result of determinants mainly with the number of frequency was simplified, with little consideration of weighting or quality for the lack of critical appraisal. Dimensions of the same scale (R-DBS) were counted multiple times, and multi-item polytomous validated scales were treated on equal counts to single dichotomous unvalidated items. Moreover, determinants were not clearly categorised to be mutually exclusive, especially psychological and behavioural factors, for their abstract nature. For example, combined themes (eg, empathy in communication^17,26) and contiguous terms used simultaneously (eg, control/anxiety,²⁶ confidence/trust²⁸) were counted separately irrespective of their collectivity and ambiguity. Thus, it would not be fair to say that “trust” is twice as determinative as “dental fear/anxiety” for DPR based on their numerical records. Rather, they have been suggested to be determinants of DPR at different times depending on the context where the research was conducted and interpretation at the researchers’ own discretion. Nevertheless, this scoping review could explore determinants of DPR comprehensively, not for a single focussed factor, by following a systematic approach for reproducibility and robustness of search.

Practical implications

The findings of this review can be helpful to conceive an in-depth framework of DPR for future studies, considering its complex and interdisciplinary structure.⁸ The framework may need to reflect dentists’ perspective of DPR as one of the main players in the dyad for its mutuality.³⁴ In addition, now that a scoping review has been performed as a preliminary step,¹⁴ systematic reviews with specific research questions about DPR are encouraged for the synthesis of rigourous evidence from critical appraisal. For practical implications, we could confirm the significance and benefit of DPR, not least communication and trust in clinical encounters. A better DPR should be achieved along with other components in quality of care³⁷ for favourable oral health outcomes.

Conclusions

Previous literature about DPR has indicated a few common and dentistry-specific determinants from patients’ perspective. “Communication,” “trust,” and “autonomy,” consisting of “control” and “decision-making involvement,” were more frequently identified common determinants, with “dental fear/anxiety” distinctively found in dental contexts. As this scoping review reconnoitred¹² for the determinants of DPR, further studies—possibly systematic reviews—are advised to establish a well-structured framework of DPR including but not limited to measuring and developing DPR in all relevant domains.

Conflict of interest

None disclosed.