Components of patient satisfaction with a dental restorative visit: results from The Dental Practice- Based Research Network

Abstract

Objectives

Identify components of patient satisfaction with a dental restorative visit; and test the hypothesis that certain dentist, patient, and procedural factors are associated with patient satisfaction.

Methods

197 practices in The Dental Practice-Based Research Network (DPBRN) recruited consecutive patients with defective restorations that were replaced or repaired in permanent teeth. At the end of the treatment visit, each subject was asked to complete a satisfaction survey and mail it directly to the DPBRN Regional Coordinators.

Results

Analysis of 5,879 satisfaction surveys revealed three satisfaction components which were interpersonal relationship-comfort attributes; material choice-value factors; and sensory-evaluative features. Satisfaction was highest among patients who received care in a private practice model; when the restoration was repaired rather than replaced; or when the restored tooth was not a molar.

Conclusion

These data suggest that a patient’s judgments of dentist’s skills and quality of care are based on personal interactions with the dentist, the level of comfort, and post-treatment sensitivity. These conclusions have direct implications for patient management before, during and after the procedure.

Practice implications

When taking a patient-centered approach, dentists should seek to understand how patients evaluate and rate the service provided, facilitating a focus on what each patient values most.

INTRODUCTION

Patient satisfaction can impact a patient’s likelihood of choosing a dentist, making and keeping appointments, and complying with dentists’ recommendations.^(1–5) Therefore, patient satisfaction is an important component of health care and one that has the potential to impact general dentistry treatment outcomes.^(6–8) Satisfaction can be considered a combination of the discrepancy between patients’ expectations and their experiences.^(9–11) A comprehensive review by Newsome and Wright concluded that five generic issues affect dental patient satisfaction: 1) technical quality of care; 2) interpersonal factors; 3) convenience; 4) financial issues; and 5) office environment.⁽⁷⁾

It is logical that levels of satisfaction may differ depending on which dental procedures are performed, as well as which clinical populations are being served. Unfortunately, most studies of dental patient satisfaction have focused on dental visits in general ^(12,13) and have sampled from the community without regard to time lag or the nature of the dental care received by the subjects.^(3,14,15) Many studies have assessed patient satisfaction in university dental clinics, a setting for which generalizability to other practice settings may be questionable.^(2,16–18) Consequently, with the exception of prosthetic ^(19,20) and orthodontic procedures,⁽²¹⁾ there is little information about dental patient satisfaction among patients who have received a homogenous set of dental procedures. The placement or replacement of dental restorations is the most commonly performed procedure by general dentists ^(22,23) and little is known about patient satisfaction with restoration visits.^(13,24)

Therefore the purposes of this study were to; 1) develop a measure of patient satisfaction with a dental restoration visit; 2) identify components of patient satisfaction; and 3) test the hypothesis that certain dentist, patient, and procedural factors are associated with patient satisfaction.

RESEARCH DESIGN AND METHODS

Network Dentists

The research setting was “The Dental Practice-Based Research Network (DPBRN)” a consortium of dental practices that conduct research with the ultimate goal of improving quality of care. DPBRN emphasizes doing “practical science” about, in, and for the benefit of "real world" clinical practice. This means that the practitioner-investigators themselves actively participate in developing ideas for studies as well as in designing, conducting, and communicating this research - all with the intent of having a direct, practical impact on everyday clinical practice. Many details about DPBRN are publicly available at its web site,⁽²⁵⁾ but briefly, it comprises practitioner-investigators and staff in outpatient dental practices from the United States and Scandinavia, but mainly from five regions: AL/MS: Alabama/Mississippi, FL/GA: Florida/Georgia, MN: Minnesota which includes both dentists employed by HealthPartners Dental Group (http://www.healthpartners.com/) and community practitioners, PDA: Permanente Dental Associates (http://permanentedental.kpnw.org/) in cooperation with Kaiser Permanente’s Center for Health Research, and SK: the Scandinavian countries of Denmark, Norway, and Sweden. DPBRN has a wide representation of practice types, treatment philosophies, and patient populations, including diversity with regard to the race, ethnicity, geography and rural/urban area of residence of both its practitioner-investigators and their patients. Analyses of these characteristics confirm that DPBRN dentists have much in common with dentists at large,⁽²⁶⁾ while at the same time offering substantial diversity with regard to these characteristics.⁽²⁷⁾

DPBRN practitioner-investigators were recruited through continuing education courses and/or mass mailings to licensed dentists within the participating regions. As part of the eligibility criteria for the study in this report, all dentists completed (1) an Enrollment Questionnaire describing their demographic and practice characteristics and certain personal characteristics, (2) an Assessment of Caries Diagnosis and Caries Treatment questionnaire, (3) training in human subjects’ protection, and (4) attended a DPBRN orientation session or watched a video of it, and (5) had a protocol-specific training session with the regional coordinator in their practice. Copies of these questionnaires are available at http://www.dentalpbrn.org/users/publications/Supplement.aspx . This study was approved by the respective Institutional Review Board of each participating region.

Recruitment and data collection

The overall project involved collecting clinical data on the restorative treatment, a survey assessing patient satisfaction with the visit, and a longitudinal follow-up of the restorations. Each participating dentist/practice (n=197, see Table 1) recruited consecutive patients with defective restorations that were replaced or repaired in permanent teeth. The initial contact with potential patient-participants was made by office staff. If interested, the study was explained and patients were given informed consent and provided with the study materials. Each subject was given the Satisfaction Survey Form – along with a stamped envelope and was asked to mail a completed survey the next day. The completed survey was mailed directly to the DPBRN Regional Coordinators to ensure that the dentist remained blinded to patient satisfaction ratings. The day of the dental visit, a reminder card was mailed to each patient reminding them to complete and return the satisfaction survey. Once the patient questionnaire was received at the regional administrative site, each participant was either mailed a $10 incentive card or received a gift bag of the same value.

Table 1.

Dentist, patient, and procedural characteristics

Variable	Mean (SD) or % (n)
Dentists characteristics (n=197)
Gender (male)	70% (n=138)
Years since dental school graduation	18.7 (SD=10.0)
Full-time (32+ hours per week in patient care)	86% (n=162)
Percent of time spent on non-implant restorations	56% (SD=20)
Practice model used by dentist
SGP	57% (n=112)
LGP	37% (n=72)
PHP	7% (n=13)
Practices by region
Alabama/Mississippi	20% (n=39)
Florida/Georgia	22% (n=44)
Permanente Dental Associates	20% (n=40)
HealthPartners and practitioners in Minnesota	18% (n=36)
Scandinavia (Denmark, Norway, Sweden)	19% (n=38)
Patients characteristics (n=5405)
Patient gender (male)	42% (n=2242)
Patient age	52.3 (SD=15.4)
Patient race
White	91% (n=4893)
Black or African-American	5% (n=281)
Asian	1% (n=60)
American Indian or Alaskan Native	< 1% (n=34)
Native Hawaiian or Other Pacific Islander	< 1% (n=34)
Other	1% (n=58)
Missing	1% (n=73)
Patient Hispanic/Latino ethnicity
Hispanic/Latino	17% (n=907)
Not	81% (n=4410)
Missing	2% (n=88)
Patient was seen in a given practice model
SGP	60% (n=3262)
LGP	35% (n=1883)
PHP	2% (n=88)
Number of restorations that the patient had during the visit
Single restoration	77% (n=4138)
Two restorations	18% (n=954)
Three restorations	4% (n=227)
Four restorations	2% (n=86)
Percent of patients who did not have dental insurance	78% (n=4213)

Development of the Survey

The survey development began by interviewing 15 patients who had a recent restorative visit and 16 practicing dentists. The interviews were aimed to identify the specific characteristics of tooth restoration visits that are important to patients. The characteristics reported during the qualitative interviews, along with those identified during the comprehensive literature review, were used to construct a 40-item preliminary instrument to determine the relative importance of each characteristic towards patient satisfaction during a restoration visit. The initial draft was evaluated and modified following comments provided by several experts in the restorative dentistry field. The original 40-Item pool was divided into common domains of 1) Relationship with the dentist, 2) Technical ability of the dentist, 3) Comfort/Pain free visit, 4) Restorative material, 5) Communication about treatment, 6) Office environment, 7) Communication- Interpersonal, 8) Waiting at the office, and 9) Cost. A patient and dentist version were designed which used the same questionnaire items. However, the instructions asked about patient’s satisfaction from the patients’ viewpoint or dentist’s perceptions of patients’ viewpoint. This preliminary version was administered to 19 dentists and 39 persons with a restoration-related dental visit within the previous year. The goal for selecting items for the final survey was to have items highly rated as important towards patient satisfaction and with broad content. When three or four items within a domain were highly rated, we attempted to select items with lower inter-domain correlations to reduce redundancy. A single item was selected from the waiting time, cost-benefit, and office environment domains because of the relatively lower importance ratings. The final 20-item instrument included items from each of the above 9 dimensions (see Table 2) with test-retest coefficients ranging from 0.95 for “How my dentist limited pain during the procedure” to .83 for “How the filling looks”.

Table 2.

Mean bootstrap factor loading and standard deviation.

How satisfied were you with ….	Item Mean (SD)	Relationship- comfort Mean factor loading (SE)	Material- value Mean factor loading (SE)	Sensory- evaluative Mean factor loading (SE)
The friendliness of my dentist.	4.8 (0.5)	.89 (.05)
How friendly and courteous the staff was.	4.8 (0.5)	.86 (.06)
How much my dentist cares about me as a person.	4.6 (0.6)	.85 (.07)
How my dentist tried to limit my fear and anxiety.	4.6 (0.7)	.73 (.07)
The skill of my dentist.	4.7 (0.5)	.72 (.08)
How my dentist limited pain during the procedure.	4.7 (0.7)	.69 (.08)
The amount of trust that I can place in my dentist.	4.6 (0.6)	.66 (.09)
How gentle my dentist was when working in my mouth.	4.5 (0.6)	.63 (.09)
How clean and organized the office was.	4.6 (0.6)	.49 (.10)
How long I had to wait in the waiting room.	4.3 (0.7)	.45 (.10)
My dentist gave me a choice between different materials to fix my tooth.	3.9 (1.1)		.87 (.05)
How long I expect the filling to last.	4.2 (0.8)		.66 (.07)
That my dental fee was reasonable for the work done.	4.1 (1.0)		.65 (.08)
The dental procedure was explained before it was started.	4.4 (0.8)	.36 (.12)	.57 (.08)
I was able to ask questions about the dental procedure.	4.5 (0.6)	.35 (.13)	.56 (.10)
How the filling feels with hot or cold foods or drink.	4.5 (0.7)			.89 (.06)
That the filling was not sensitive when I bit down on it.	4.6 (0.6)			.74 (.07)
The quality of the dental work.	4.6 (0.6)	.34 (.13)		.56 (.09)
The filling feels smooth when I tough it with my tongue.	4.5 (0.7)			.48 (.11)
How the filling looks.	4.5 (0.7)		.35 (.11)	.47 (.13)

Survey instructions. We want to know how satisfied you were with different aspects of your dental treatment and visit. Please circle the number that best indicates how much you agree or disagree with that statement. Response choices were: Strongly disagree=1, Disagree=2, Neither agree nor disagree=3, Agree=4, Strongly agree=5.Note: Factor loadings are correlations between items and the factor. Factor loadings of 0.50 and greater are typically used in interpreting a factor, with higher loadings designating greater contributions to the factor.

Data Analysis

Data screening

The data were screened and missing values were identified. Patients who failed to complete one or more satisfaction items were identified and dropped from further analysis.

Data reduction

To determine the initial dimensions, two factor extraction and two rotation algorithms were used to allow for replication of factor structures. Items with factor primary or secondary loadings of ≥0.30 were included in the confirmatory model. The sample was randomly divided using a 50/50 split so that different samples were used for the exploratory and confirmatory factor procedures. The factor models evidenced in the previous step were verified using confirmatory factor analysis with bootstrap sampling (Table 2 for mean factor loadings).^(28,29)

Characteristics associated with satisfaction factors

The General Linear Model, using GEE to adjust for clustering within dental practices and patients, was used to examine dentist, practice, patient, and treatment variables as predictors of each of the satisfaction dimensions. Dentists associated with PDA or HealthPartners were categorized as large group practice model (LGP). Other practices were assigned by regional coordinators to the categories of solo private practice or small group practice (less than four dentists; SGP) or public health practice (PHP). Other variables included in the models are described in Table 3.

Table 3.

Predictor variable (reference)

	Relationship-comfort		Material choice-value		Sensory-evaluative
	B (SE)	p value	B (SE)	p value	B (SE)	p value
Dentist characteristics
Dentist gender (male)	-----		-----		.086 (.049)	.080
Years since graduation	.008 (.003)	.002	-----		.005 (.002)	.019
Percent of practice restorative	-----		.062 (.001)	<.001	.002 (.001)	.029
Large group practice (SGP)	.251 (.051)	<.001	.280 (.040)	<.001	.284 (.045)	< .001
Public health practice (SGP)	.334 (.087)	<.001	.075 (.224)	.224	.088 (.052)	.090
Patients characteristics
Age in years	.005 (.001)	<.001	.003 (.001)	.012	.009 (.001)	<.001
Patient gender (female)	.076 (.030)	.011	.060 (.029)	.045	−.057 (.032)	.069
Tooth-specific characteristics
Dentist placed existing restoration (yes)	.074 (.030)	.040	-----		-----
Treatment (repair)	.098 (.040)	.015	.083 (.040)	.041	.089 (.037)	.017
New material direct (amalgam)	-----		-----		−.171 (.052)	.001
New material indirect (amalgam)	−.116 (.053)	.028	−.187 (.049)	< .001	−.132 (.054)	.015
Tooth – premolar (molar)	-----		−.110 (.038)	.004	−.131 (.038)	.001
Tooth – incisor (molar)	-----		−.247 (.063)	<.001	−.151 (.068)	.027

The dependent variables for these analyses were weighted factor scores which were calculated using mean factor loadings from the bootstrap procedure and converted to z-scores with a mean=0 and a standard deviation=1.0. Interpretation of B: when predictor is categorical, B is the mean for the tested group when the mean for the comparison group is 0. When B is a metric variable, it is the change (in SD units) in the DV associated with a one unit change in the predictor variable.

A backward elimination approach was used that removed the least significant variable from the model in subsequent steps until all remaining variables were significant using p <0.15 for retention (Menard 1995). Dentist and patient gender (male=0, female=1) and type of practice model (PHP/LGP=0, PP=1) were coded as indicated.

Days wait for a treatment visit, full/part time status, dental insurance, the number of restorations treated on this visit, whether a dam was used, upper/lower arch, and the original restoration material (amalgam, direct composite, or indirect composite) were tested in the original models but were not significant and dropped during the backward elimination procedures.

RESULTS

Network dentists returned completed restorative data forms for 7,286 patients enrolled in this study. The DPBRN Regional Coordinators received a total of 5,879 surveys from these patients (compliance rate of 81%). Of these, 92% (n=5,405) had completed all of the survey items and provided the data used for this paper (patient characteristics are presented in Table 1). Patients who failed to complete all items were older (58.6 years, SD=15.6) than completers (52.3, SD=15.4) and more likely to have been seen in a PHP (13%) compared to SGP (8%) or LGP (7%). Additional information related to patient compliance is available on the Supplements page at http://www.dentalpbrn.org/users/publications/Supplement.aspx.

Exploratory and confirmatory factor analysis (CFA)

The primary loadings on Factor 1 consisted of items describing the perceived interpersonal relationship with the dentist and questions related to comfort during the treatment. This factor was labeled “Interpersonal relationship-comfort”. The second factor involved items about patient involvement in treatment decisions and perceived value of the procedure. This factor was labeled “Material choice-value”. The highest loadings on the third factor described sensory aspects of the restoration following the procedure. This factor was labeled “Sensory-evaluative”. Tables 2 presents the tested factor structure and mean bootstrap loadings from the CFA. Additional information on the factor procedures are available on the Supplements page at http://www.dentalpbrn.org/users/publications/Supplement.aspx.

Characteristics associated with satisfaction factors

Results from the regression analysis are summarized in Table 3.

Interpersonal relationship-comfort

A greater number of years since dental school graduation (p=.002) and patient’s age (p<.001) were positively associated with ratings of satisfaction on the Interpersonal relationship-comfort factor. Dentists received higher ratings of satisfaction when they used a private practice model compared to dentists who belonged to a LGP or PHP (both at p<.001) or when the patient was female compared to male (p=.011). Higher ratings of patient satisfaction were expressed when the dentist had placed the original restoration (p=.040), when the defective restoration was repaired rather than replaced (p=.015), and when the new material was an indirect tooth colored material compared to an amalgam (p=.028).

Material choice-value

The percent of time that the dentist typically spends each day doing non-implant restorative procedures (p<.001) and patient’s age (p=.012) were positively associated with ratings of satisfaction on the material choice-value factor. Additionally, dentists using a SGP model or when the patient’s gender was female had significantly higher ratings of satisfaction than LGP dentists (p<.001) or when the patient was male (p=.045). Having the defective restoration repaired rather than replaced (p=.041), when the new material was an indirect tooth colored material compared to an amalgam (p<.001), and when the tooth was a premolar (p=.004) or an anterior tooth (p<.001) compared to a molar, were associated with higher ratings of satisfaction within the material-choice domain.

Sensory-evaluative

A greater number of years since dental school graduation (p=.019), percent of time that the dentist typically spends each day doing non-implant restorative procedures (p=.029), and patient’s age (p<.001) were positively associated with ratings of satisfaction on the sensory-evaluative factor. Dentists using a SGP model had significantly higher ratings of satisfaction than LGP dentists (p<.001). Having the defective restoration repaired rather than replaced (p=.017), when the new material was a direct tooth-colored material (p=.001) or an indirect tooth-colored material (p=.015) compared to an amalgam, and when the tooth was a premolar (p=.001) or an anterior tooth (p=.027) compared to a molar, were associated with higher ratings of satisfaction on the sensory evaluative features.

DISCUSSION

This study examined satisfaction ratings of patients who had received treatment for a defective restoration. The measure of patient satisfaction was developed specifically for restorative procedures and the large sample allowed the use of sophisticated statistical procedures to test for multiple components within the patient satisfaction data. The three components identified were a set of interpersonal relationship-comfort attributes, material choice-value factors, and sensory-evaluative features, and each reflects a complex set of objective and subjective elements. Overall, the patient’s satisfaction levels were high, and our ratings are similar to those reported by another study using similar response choices.⁽³⁰⁾ Interesting findings included that patients were more satisfied when the restoration was repaired rather than replaced and when the restored tooth was a premolar or anterior tooth and not a molar.

We are able to find only two studies that have measured patient satisfaction with any direct relationship to dental restoration visits. Goedhart et al.⁽¹³⁾ investigated the importance of 56 qualities of dental care in a sample of dental attendees in Holland. Among the top-rated 10, three were related to a dental restoration: “Your teeth close well after a filling has been made, so the filling is not too high”; “The filling in a front tooth is invisible”; and “Dental restorations should hold out for at least four years”. Abrams et al. compared the patient’s perception of the quality of past dental care, a standardized index of restoration quality, and recall of overall satisfaction with past visits.⁽²⁴⁾ Neither patient satisfaction nor the item about the quality of past treatment were associated with the restoration index score. The Abrams study is the only one that has tested patient’s accuracy in evaluating dentist’s technical skills.

Components of satisfaction

The first component constituted items describing the patient’s immediate experiences during the visit. This includes the perceived interpersonal relationship between patient and dentist and several questions related to comfort during treatment that may represent the patient’s view of the skills of the dentist (i.e., a skillful dentist is a painless dentist). Certainly the technical aspects of a dental procedure are complex – and a clear outcome is often not immediately evident. Consequently, patients likely use a combination of subjective and objective experiences to make this evaluation.⁽²⁴⁾ Several studies have shown that patients evaluate the quality of their dental care according to a range of criteria, particularly their dentist’s interpersonal communication.^{(2,3,12,31–34)} For example, Holt and McHugh demonstrated communication of care and attention to be the most influential when determining dentist loyalty.⁽³⁾ Other studies have also found that whether the dentist responds to your pain, discusses your fears, and helps you to overcome them were very important to patient satisfaction.^(32,33) Our data also suggest that patients infer dental skill from the dentists’ ability to control pain and provide a visit that is free from any negative experiences.⁽³⁵⁾

The next component described a combination of patient involvement in treatment decisions and perceived value of the treatment. There is a robust literature about the importance of involving patients in treatment decisions in medicine,^(36,37) and some for dental prosthetic procedures,^(38,39) but there is limited information about the importance of communication to patients during restorative procedures. A prudent dentist extends the traditional components of informed consent to educate patients more completely, provides time for patients to comprehend the facts and to have their questions satisfactorily answered.^(40–42) One study has shown that patients who received more preparatory information and knowledge had superior postoperative pain control and satisfaction following third molar surgery than patients who did not.⁽⁴³⁾

The final component was related to the sensory experiences following the procedure; items that asked about hot/cold sensitivity and comfort when biting. The current study was designed so that patients completed the study questionnaire after leaving the dental office with the purpose to provide sufficient time for the anesthetic to wear off, so that patients could make a more valid assessment about the comfort of the restoration. Both amalgam and composite restorations are known to be associated with post-operative sensitivity.^(44–47) The fact that these two items were highly correlated with another item that asked about the quality of the dental work suggest that sensory factors influence how quality of care is evaluated. A limitation to any conclusion about provides’ skills is that they are based on correlational analyses.

Factors associated with patient satisfaction

Lower ratings of patient satisfaction were found when the new restoration material was amalgam and when the tooth was a molar, for both the material choice-value factor and sensory-evaluative components. Certainly there is controversy about amalgam as a restorative material ⁽⁴⁸⁾ and patients may feel strongly or at least desire some input about its selection. A recent study has shown that many dentists prefer amalgam when restoring molar teeth in patients with high caries risk;⁽⁴⁹⁾ this preference may override any discussion with the patient. It is also possible that the restorations done in molar teeth were larger and more-challenging to restore, or had more post-operative sensitivity. It is interesting that levels of satisfaction were similar between restorations in the lower or upper arch, even though the anesthetic injections required for lower-arch procedures are typically more-painful. We speculate that more-experienced dentists were rated higher than recently graduated dentists because of greater proficiency in patient management and communication, as well as greater technical skills and speed that had been developed during more years of clinical experience.

Dentists in SGP practice had the most-satisfied patients, although most patients from all three practice models were very satisfied with all components of their treatment and visit. It may be that SGP practitioners in the United States are more prone to offer alternative treatments and not required to follow certain pre-approved treatment protocols, and this discussion with patients creates good will even though the same end point is achieved. It is also possible that network dentists in SGP practices are more self-selected, as all (or nearly all) members of participating LGP practices are DPBRN members.

Implications

When taking a patient-centered approach, practicing dentists should seek to understand how patients evaluate and rate the dental service provided, facilitating a focus on what each patient values. Studies have shown that a dentist’s technical competence is a high priority for patients,⁽¹³⁾ but patients may use non-technical aspects of the visit in this appraisal.⁽⁵⁰⁾ Our results suggest that patients’ judgments of their dentists’ skills and quality of care are in part based on personal interactions with their dentists, the level of comfort, and post-treatment sensitivity. These conclusions have direct implications for patient management before, during and after the procedure. Corrective steps could include changes in office policies or procedures, patient education, or even changes in the dentist's interpersonal approach. Dental practitioners should remain vigilant of the human and psychological aspects of care and remain cognizant that they are integral components of the quality of care provided.