Trust and Distrust in Dental Professionals: Patient Perceptions and Experiences

ABSTRACT

Purpose

To investigate factors that contribute to trust in dentists among patients with socioeconomic barriers and explore how these factors influence patient decisions to undergo dental treatment.

Methods

Patients at the University of Toronto, Faculty of Dentistry, participated in one‐on‐one semi‐structured interviews, answering open‐ended questions about circumstances that led to the development and erosion of trust. Interviews were recorded, transcribed verbatim, and coded. Thematic analysis was used to organize data from transcripts and develop themes.

Results

Interviews were conducted with 25 patients (18 females, 7 males; age range 22–68 years). Four themes were developed: (1) Patients’ perception of dentists’ technical skills and reputation was important to building trust. Dentists perceived by patients to provide high‐quality work, minimize pain, use current technology, and have positive endorsements led to trust. (2) Patients’ perception of dentists’ communication skills and empathy was important to building trust. Patients reported having trust in dentists who communicated treatment details, remained transparent, engaged them in decision‐making, and prioritized their well‐being. (3) Patients varied in how they associated trust with cost and their previous dental experience. (4) Trust influenced patient decisions to proceed with dental treatment.

Conclusions

Trust is a dynamic component of the dentist–patient relationship that patients assess throughout their treatment‐seeking process. Empathy and communication skills are modifiable attributes that dentists can develop to build their patients’ trust. Dentists have less control over how patients perceive their competence. Patient trust in dentists fosters active engagement in treatment, while distrust can lead to switching dentists or avoiding treatment.

1. Background

Trust in a relationship involves one party assuming a vulnerable position and another acting according to the vulnerable party's best interests [1]. In a dentist–patient relationship, trust is a complex, multi‐dimensional element that benefits both parties [2], and can be understood as the healthcare provider “acting as an advocate of the patient's best interest” [3]. Patients with higher trust in their dentist report fewer symptoms related to oral disease, improved quality of life, and increased patient satisfaction [4, 5]. Furthermore, trust fosters open and honest communication, allowing dentists to provide more comprehensive and personalized care [6, 7]. Distrust, the erosion of trust, leads to the avoidance of dental care, worse health outcomes, and reduced patient compliance while simultaneously being a source of stress for dentists [4].

The consequences of distrust in dentists are exacerbated in certain communities, including low‐income patients who already experience disproportionately high morbidity from oral disease [8]. In particular, low‐income populations have more oral health needs, are at higher risk of developing caries and periodontitis, and face more barriers to accessing care [9, 10, 11]. The high cost of services, lack of dental insurance, and prioritization of basic needs are examples of barriers this group faces in accessing dental care [10, 11, 12]. A poor trust relationship between the dentist and the patient has also been identified as a major barrier [13]. Low‐income patients who report lower trust in their dentist also report worse oral health outcomes, further highlighting trust as a vital component of the dentist–patient relationship [14, 15].

While trust has been extensively studied in physician–patient relationships, there is limited research pertaining to the dentist–patient relationship [16, 17]. Existing research investigating trust in the dentist–patient relationship primarily relies on structured questionnaires derived from medicine [3, 11]. These questionnaires do not encourage the exploration of perspectives; instead, they provide decontextualized data [4]. To address this limitation of prior research, qualitative methodology was used to study the concept of trust, as it is suited for exploring complex phenomena about which little is known [18]. Currently, there is a lack of understanding of how dentists facilitate the trust‐building process and the impact of trust on the patient experience. Competence, behavioral, and emotional dimensions of trust have been identified in the literature [6]; however, it remains unclear which dimensions are most important to dental patients and how they affect patients’ treatment‐seeking behaviors [3]. If dentists are unaware of how to build patient trust, both parties may continue to experience the negative outcomes associated with distrust. In this study, we explored trust in dentists from the perspective of patients with socioeconomic barriers and past dental experiences.

2. Methods

2.1. Study Design

A qualitative descriptive approach was chosen, as it enables the exploration of individual experiences and personal contexts related to trust as a topic of interest [19, 20]. This approach allowed an in‐depth study of participant perspectives [19, 20]. Ethical approval was obtained from the University of Toronto Research Ethics Board (Protocol #39888).

2.2. Participant Recruitment

In the One Smile program at the University of Toronto, Faculty of Dentistry, patients participate in research surveys that investigate how free dental care affects their overall health, life satisfaction, and employability in exchange for free dental care. To be accepted into this program, the individual must have experienced a financial barrier to accessing dental care in the two years before registering for the program and be able to speak, read, and understand English. Patients enrolled in the One Smile program were contacted to participate in an in‐person, one‐on‐one, semi‐structured interview discussing the concept of trust in the dentist–patient relationship. Purposeful sampling was employed, which facilitated the recruitment of information‐rich cases [22]. Criterion sampling, a form of purposeful sampling, is recommended when exploring how an experience has influenced an individual's perception of it [22]. In addition to the acceptance criteria for the One Smile program, participants had to be 18 years of age or older and have had prior dental experiences to be included in our study, as it allowed us to investigate how those experiences influenced their perception of trust in their dentist. Individuals were excluded if they had never received dental care. A recruitment leaflet was provided to the participants describing the study's purpose and what was to be expected during the interview. Eligibility was confirmed by telephone before scheduling an interview. Participants were informed that participation was voluntary, confidential, and would not affect future treatment. Interviews were conducted in the dental clinic, and demographic information and a signed consent form were collected. Financial compensation was not offered for participation.

2.3. Data Collection

Participants were interviewed before or after their appointment with the dentist. A semi‐structured interview guide was developed that focused on patients’ past dental experience and what was important to participants in trusting a dentist. Each interview began with an open‐ended question asking the participant to describe their dental experience. Subsequent open‐ended questions were based on areas identified from existing literature that included qualities of dentists that fostered and eroded trust, participants’ opinions about establishing trust, and how trust influenced participants’ dental treatment‐seeking behavior [7]. We developed questions that asked participants to define trust, the duration needed to develop trust with their dentist, and the impact of trust on the dentist–patient relationship. Open‐ended questions allowed participants to provide more in‐depth responses to their experiences, thoughts, and feelings compared to closed‐ended questions, allowing for an improved understanding of processes and potential relationships between trust and engaging in treatment [23, 24]. Open‐ended questions also enabled the research team to identify new perspectives that had not been initially considered and provided insight into topics most important to participants as opposed to a limited set of responses in closed‐ended questions [23, 24].

Participants were prompted to express themselves freely and discuss any concepts or interpretations they deemed relevant. Probing techniques were used to facilitate in‐depth discussion and to clarify any ambiguous responses [19]. Data collection and analysis followed an iterative process, whereby data collection and analysis occurred concurrently, and the analytical process adapted to new insights as these insights were developed. We recruited patients until we deemed that data saturation had been reached, which was the point at which additional data did not improve understanding of the phenomenon under study [25]. Interviews were conducted by one dental student (KH) at the University of Toronto to promote consistency in data collection during the study period between July 2023 and June 2024.

2.4. Data Analysis

Thematic analysis was used to develop concepts based on the data collected [26]. First, three interviews were audio‐recorded, transcribed verbatim, and read by the research team (KH, LD, JS) for data familiarization. Next, codes were created in NVivo12 software to represent all meaningful segments of the transcripts and were revised based on discussions among the three researchers (KH, LD, JS). The first author (KH) then read and coded the remaining transcripts. Codes related to similar concepts were categorized into broader themes. These themes were compared to our transcripts again and refined to promote accurate data representation. Finally, a report was created based on these themes [26].

2.5. Strategies to Increase Rigor

To increase the quality of the data collected, KH was trained by experienced qualitative researchers (LD, JS) to conduct semi‐structured interviews and follow up with prompts to explore answers further and request additional information. A pilot interview was completed, where LD provided feedback to KH on interviewing techniques to refine the interview protocol and conduct of subsequent interviews [27]. Reflexivity, the idea that researchers have preconceptions that influence the interpretation of findings, was practiced to enhance the rigor and credibility of our results and promote a transparent account of the data [28]. Members of the multidisciplinary team (KH, LD, JS), who have experience in education and qualitative research, engaged in several sessions of peer debriefing to practice reflexivity [27]. Where there was ambiguity in coding concepts, each researcher's interpretation was compared to reach a consensus that everyone agreed upon. KH documented his observations and reflections as a dental student after conducting the interviews, which were later revisited to assess how personal views might have influenced data interpretation; this aligns with the recommended reflexivity process [29]. Finally, direct quotes from participants were reported to support our results [30, 31].

3. Results

3.1. Participants

A convenience sample of 40 patients in the One Smile program was approached to participate in this study, and 25 individuals consented to participate (62.5% response rate). The remainder of the patients did not consent to participate due to scheduling conflicts (n = 12) and lack of interest (n = 3). Table 1 describes participant demographics related to age, sex, level of education, and past dental experience. Interviews ranged from 20 to 79 minutes. Data saturation was considered to be reached by the research team prior to the 25th interview; however, additional interviews were conducted to confirm that no new data were obtained that furthered our understanding of the development and erosion of trust. Trust was identified as a dynamic component of the dentist–patient relationship that patients assess throughout their treatment‐seeking process. Four themes were developed that described this process. Table 2 is a summary of exemplar quotations that supported these themes.

TABLE 1.

Participant characteristics (n = 25)

Characteristic
Age range	22–68 years
Mean age (Standard deviation)	38 (11) years
Median age	37 years
Sex	n (%)
Female	18 (72%)
Male	7 (28%)
Highest level of education completed
Less than high school	2 (8%)
High school	4 (16%)
College, trade school, or university certificate	8 (32%)
University degree	6 (24%)
Graduate degree	3 (12%)
Prefer not to answer	2 (8%)
Type of past dental experience(s)
Positive	11 (44%)
Neutral	8 (32%)
Negative	6 (24%)

TABLE 2.

Exemplar quotes representing trust and distrust based on themes 1–3.

Trust	Supporting quotes	Distrust	Supporting quotes
Theme 1: Patients’ perception of dentists’ technical skills and professional reputation was important to building patient trust.
The dentist produces long‐lasting, high‐quality work	Participant 15 (P15): “Quality work. Work that doesn't fail quickly, like a filling that has to be redone every few years.”	The dentist produces work that requires frequent repair, replacement, or additional treatment	P19: “If they mess up a few times in a row, like 3 times in a row, I wouldn't trust them… [For example] if they were supposed to do a little filling, but then it goes on to become a root canal”
The dentist provides adequate pain management	P12: “The less pain I experience, then I trust more.”	The dentist provides inadequate pain control	P20: If [the dentists] don't care about the patient and won't help patients relieve their pain, I would not go back.
The dentist uses current technology and techniques	P25: “[Trust] is also based on staying up to date with materials and technology.”	The dentist uses outdated technology and treatment methods	P11: “The first [surgery's] technique was old and wouldn't give the best results. I had pain because of the technique.”
The dentist has positive endorsements	P8: “I think when you have so many people go to the same person, and then give you good feedback, it helps you develop trust.”	The dentist has poor reviews or recommendations	P5: “If I want to choose a new dentist, I would go and read their reviews… If they were all bad reviews, I wouldn't [trust them].”
Theme 2: Patients’ perception of dentists’ communication skills and empathy was important to building patient trust.
The dentist explains all aspects of treatment	P13: “If they explain the process to me before starting, I trust them. I have to understand everything.”	The dentist does not explain all treatment details	P24: “I did not trust one of [the dentists] because they were supposed to work on one tooth but ended up working on two other teeth. They should not have started on those. They didn't even ask me.”
The dentist remains transparent with proposed treatments and costs	P15: “This links back to transparency, like this is what we need to do, we might be able to do this, this is what we recommend, we don't recommend this… this is how much it is going to cost, this is how much we will charge with your benefits.”	The dental team provides inconsistent information to patients	P2: “My trust was broken because I was told one thing [by the hygienist] and then the dentist told me something different after.”
The dentist demonstrates a caring demeanor and prioritizes patient's well‐being	P23: “They will take care of you emotionally, mentally, and physically throughout the entire procedure. You know that you are in good hands and you will be okay no matter what happens.”	The dentist overlooks patient needs	P3: "I built resentment towards dentists because they didn't understand mental illnesses and anxiety of dentists.”
The dentist involves the patient in the decision‐making process	P14: “[The dentist] tells me that there are different ways to do the treatment and the decision can be made together. It is very important for me.”	The dentist excludes the patient from the decision‐making process	P25: “I distrust when they don't involve me when making decisions [and when] they just force one option on me.”
Theme 3: Patients varied in how they associated trust with cost and their previous dental experience.
Some participants associated higher cost with high‐quality work, leading to trust	P5: “I trust that if they are charging me a higher fee, I will have higher quality work done.”	Some participants associated lower cost with low‐quality work, leading to distrust	P7: “There are [clinics] for low‐income [patients] that accept lower fees. All of those were unhelpful… With one low‐cost clinic, the filling fell out the same day.”
Some participants did not associate previous dental experience with the ability to trust a new dentist	P4: "I don't lose trust in all dentists because I know there are good and bad professionals in all areas.”	Some participants associated negative previous dental experience with a hindered ability to trust a new dentist	P21: “If you're young and don't have trust in a dentist, it will stick with you for the rest of your life.”

Theme 1: Patients’ perception of dentists’ technical skills and professional reputation was important to building patient trust.

Approximately half (48%) of the participants (P) reported that their decision to trust their dentist was based on their perception of the dentist's competence, including the dentist's technical skills and professional reputation. As shown in Table 2, patients developed trust based on their perception of dentists' technical skills, which involved providing long‐lasting, high‐quality work. P15 described these skills as, “Quality work. Work that doesn't fail quickly.” Our participants had treatment objectives they wanted their dentist to meet, such as providing aesthetic prosthetics. If their objectives were met, they perceived their dentist to be competent, leading to trust. P12 stated, “If I see good results, like a beautiful smile, that makes me trust.” Distrust arose when a dentist's technical skills were perceived by patients as inadequate, such as work requiring frequent repair, replacement, or additional treatment. P19 explained, “If they mess up a few times, I wouldn't trust them… [For example] if they were supposed to do a little filling, but then it [becomes] a root canal.” Moreover, a dentist's ability to minimize pain led to trust. This was mentioned by P12, “The less pain I experience, then I trust more.” In contrast, inadequate pain control led to distrust. P20 stated, “If [the dentist] won't help patients relieve their pain, I would not go back.” Some participants perceived that complications, such as excessive pain after dental procedures, were due to the dentist's incompetence, whereas the absence of complications was perceived by patients as their dentist having adequate technical skills. P24 noted, “Fewer complications mean I trust them more based on their competence.” Patients’ perception of the dentist's technical skills was also evaluated based on the dentist's techniques and use of technology, such as “scanners” (P6). Participants perceived a dentist who “stayed up‐to‐date with materials and technology” (P25), used the “newest technology” (P8), and had the “most recent equipment” (P8) as competent. Conversely, dentists who were perceived by patients to be using outdated technology and treatment methods appeared to lead to distrust. P11 noted, “The first [surgery's] technique was old and wouldn't give the best results.”

In addition, patients’ perception of their dentist's competence involved their professional reputation, established through peer/family recommendations, word of mouth, and/or online reviews. Many participants (64%) stated that they read through a dentist's reviews before deciding to go to them. Positive endorsements facilitated a good professional reputation, which led to trust. This was discussed by P15, “If somebody said a dentist's [quality of] work stands up, I would go to them.” Distrust arose when a dentist had poor reviews or recommendations. P5 revealed, “If [a dentist's reviews] were all bad, I wouldn't [trust them].” While participants stated that one bad review would generally not deter them from trusting a dentist, there was no consensus regarding the number of poor reviews that would lead to distrust.

Theme 2: Patients’ perception of dentists’ communication skills and empathy was important to building patient trust.

Approximately half (52%) of the participants reported that their decision to trust their dentist was based on their perception of the dentist's communication skills and empathy. Patients developed trust when they perceived the dentist to communicate all aspects of the treatment. Dentists who discussed the purpose, nature, and process of treatment, including “everything from start to end and the steps” (P12), facilitated trust. P25 explained, “Any question I ask, [the dentist] will have the answer for me and an explanation of why.” In contrast, the lack of explanation regarding proposed treatment or treatment options inhibited the trust process. P2 noted, “It doesn't help [if] the dentist doesn't explain what causes [a disease] or what the procedure is.” Furthermore, dentists who remained transparent with proposed treatments and costs helped build patient trust. This included communicating the “exact treatment” (P21) required and “not [communicating] any extra treatment that is not needed” (P21). Conversely, when different dentists or members of the dental team provided inconsistent information to patients, patient trust was diminished. P2 reported, ‘The hygienist told me that my gums and teeth were great… then the dentist [said], “We have a lot to do here”. It was confusing.’ Finally, dentists who presented treatment options and allowed patients to participate in the decision‐making process led to trust. P14 stated, “[The dentist] tells me there are different ways to do the treatment and the decision can be made together.” Distrust arose when patients were not presented with options and were excluded from the decision‐making process. P25 explained, “I distrust when they don't involve me when making decisions [and] force one option on me.”

In addition, a dentist who demonstrated empathy when treating patients, such as by showing a caring demeanor and prioritizing the patient's well‐being, led to trust. Participants expected dentists to “understand [their] emotions before starting treatment” (P13). P23 reinforced that dentists should “take care of [patients] emotionally, mentally, and physically throughout the entire procedure.” When participants’ emotional needs and challenges, such as dental anxiety, were not addressed by their dentist, distrust arose. Participants discussed how dental anxiety might lead to negative health outcomes related to distrust. P5 stated, “When you don't have trust and have anxiety, you would feel more pain.” Dentists who addressed dental anxiety facilitated trust, as discussed by P21, “I would trust a dentist who can recognize that I have dental anxiety and is attentive to my fears and needs.” Distrust arose when “[dentists] didn't understand mental illnesses and dental anxiety” (P3).

Theme 3: Patients varied in how they associated trust with cost and their previous dental experience.

Cost and past dental experience were two factors that impacted trust differently depending on the participant. Some stated they would distrust their dentist if they charged a higher fee, thinking they were being “scammed” (P4). P4 stated, “This [dentist is] scamming for more [money]. Dentists should have the same price.” Others associated low cost with low‐quality work, which led to distrust. P7 stated, “There are [clinics] for low‐income [patients] that accept lower fees. All of those were unhelpful… With one low‐cost clinic, the filling fell out the same day.” Past dental experience also appeared to play a role in shaping patient trust. Some stated that negative experiences made them less willing to trust a new dentist. P21 explained, “If you're young and don't have trust in a dentist, it will stick with you for the rest of your life.” Others with positive experiences made them more willing to trust a new dentist. However, some participants stated that previous dental experiences, whether positive or negative, did not impact their ability to trust a new dentist. P4 stated, “I don't lose trust in all dentists because I know there are good and bad professionals in all areas.” Therefore, the influence of cost and previous dental experience on trust appeared to be patient‐specific.

Theme 4: Trust influenced patient decisions to proceed with dental treatment.

Trust was identified as a dynamic component of the dentist–patient relationship. Patients considered Themes 1 and 2 throughout the dental treatment‐seeking process, as shown in Figure 1. When patients required treatment, they actively decided whether to trust or distrust their dentist. Before entering a dental clinic, trust was assessed by a patient's perception of the dentist's professional reputation. A dentist with a good professional reputation fostered trust, whereas a dentist with poor reviews inhibited the trust process. Distrust at this stage led to avoidance of treatment or switching to a new dentist. If a patient proceeded to interact with the dentist, both Themes 1 and 2 were evaluated and reassessed until the culmination of treatment. This was emphasized by P17, “After the initial trust, I have to make more investigations and communicate with them to see if I can continue to trust.” Participants who maintained trust in their dentist appeared to complete their treatment and attend regular recall appointments. When distrust occurred at any point, patients reported difficulty regaining trust and preferred to avoid treatment or switch to a new dentist. P25 highlighted this, “I don't try to regain trust with them. My business goes elsewhere.” Although most participants (80%) stated that the loss of trust in one dentist did not make them lose trust in the entire dental profession, switching to a new dentist was not always easy either, with P8 stating, “It isn't always good to switch. You never know if you're going to get a better dentist next time.” Participants appeared to value continuity of care with the same dentist. One participant, P13, stated, “Every time you change [dentists], you have to start everything again, and maybe they will forget something that was done before, and you don't know how to explain everything you've done in the past.”

FIGURE 1.

The role of trust in patient decisions to proceed with dental treatment.

4. Discussion

This study investigated factors that led to trust in dentists and their impact on the dentist–patient relationship from the perspective of low‐income patients who reported not being able to afford dental care. A strength of using a qualitative approach was the ability to capture multiple dimensions of trust and personal contexts. Participants reported positive, neutral, and negative dental experiences as well as varying levels of trust with their previous dentists. This furthered our understanding of how past dental experiences impact the development and erosion of trust. This study identified new dimensions of trust, such as patients’ perception of the dentist's empathy and professional reputation, in addition to the dimensions previously identified in the literature (e.g., competence, emotional, and behavioral) [3, 6, 13]. Furthermore, our findings demonstrated that patients’ perception of the dentist's competence, empathy, and communication skills were equally important to patients. The findings suggest that dentists should focus on their empathy and communication, as these are modifiable attributes that can be acquired and applied to any relationship. In practical terms, we recommend explaining treatment transparently and demonstrating empathy, since these skills can be learned and implemented in patient interactions [32]. Dentists have less control over patients’ subjective perception of their technical skills, as patients may not have adequate knowledge to objectively assess their dentist's work. However, we suggest establishing patient trust by demonstrating strong communication skills, as it may positively influence a dentist's professional reputation through word of mouth and/or online reviews. The influence of cost and past dental experience on trust appeared to be patient‐specific. Future research involving a larger patient population is needed to examine how cost and past dental experiences influence trust.

Although trust had previously been determined to be a critical element of the dentist–patient relationship [14, 15], our study presented original results confirming the complexity of trust in patient care. Our findings demonstrated that patients assess and re‐evaluate a dentist's technical and communication skills throughout their dental treatment‐seeking process. The dynamic nature of trust in dentistry aligns with findings in medicine, which identified trust as an indispensable element of the provider–patient relationship without which the relationship could not exist [6]. To prevent distrust, which may lead to the avoidance of dental care or switching to a new dentist, dentists can consciously work towards demonstrating effective communication skills with their patients. Avoiding dental care can lead to poor oral health consequences [33], such as pain and progression of dental disease, while switching to a new dentist requires the patient to restart the trust process without a guarantee of finding a trustworthy dentist. Given the many situations where patients can distrust their dentist along the treatment‐seeking continuum, there is a need to investigate how patient trust can be re‐established. Since the trust process is complex, re‐establishing trust may be preferable, especially in remote areas with limited access to dental care. In addition, many economically vulnerable Canadians, who previously found dental care unaffordable, can now access subsidized services through the Canadian Dental Care Plan [34]. As financial barriers are addressed, it is essential to tackle additional barriers to care, including distrust.

Study limitations related to recruitment are identified. Study participants may not have been representative of all low‐income populations, as there was no income threshold to participate in the One Smile program. Furthermore, a contextual factor that influences patient trust includes the structure and financing of dental services [13]. As Canada's dental system is largely delivered through private practice and uses a fee‐for‐service model [35], participants in this study may have perceived cost as a trust factor differently compared to patients in countries with universal dental coverage. Finally, the exclusion of non‐English speakers is a limitation of this study. Patients with limited English proficiency in English‐speaking dental clinics often experience difficulty accessing treatment due to communication challenges and cultural differences with their providers [36]. Language and cultural behaviors may affect patients’ development of trust in their dental providers, and this was not explored in our study [36, 37].

5. Conclusion

Trust is a complex, dynamic element of the dentist–patient relationship that is constantly reassessed by the patient throughout the dental treatment‐seeking process. Erosion of trust can lead patients to leave their current dentist in search of a new one or avoid treatment altogether, creating access to care barriers in populations with low socioeconomic status. Patient decisions to trust or distrust were based on their perception of the dentist's competence, communication skills, and empathy. Communication skills and empathy are modifiable attributes that we suggest dentists develop to build and maintain the trust of their patients. Dentists have less control over patients’ subjective perceptions of dentists’ competence and professional reputation. To strengthen trust, thus improving access for everyone, it is essential to invest in dentists' education to further develop their communication skills.

Conflicts of Interest

The authors declare no conflicts of interest.

He K., Sale J., Singhal S., and Dempster L., “Trust and Distrust in Dental Professionals: Patient Perceptions and Experiences.” Journal of Dental Education 90, no. 5 (2026): 647–655. 10.1002/jdd.70017