Identifying Gaps in Caries Prevention and Management: A Multi-Institutional Mixed-Methods Study

Identifying Gaps in Caries Prevention and Management: A Multi-Institutional Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Identifying Gaps in Caries Prevention and Management: A Multi-Institutional Mixed-Methods Study Suhasini Bangar, Janelle Urata, Oluwabunmi Tokede, Sayali Tungare, and 19 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7963779/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Despite established evidence-based guidelines, the prevention and management of dental caries varies across clinical settings. This study aimed to identify and understand quality gaps in caries prevention and management across four dental institutions. Methods A mixed-methods study was conducted across four large dental institutions. Three data sources were integrated: ( 1 ) structured chart reviews (n = 2,000) using six validated dental quality measures; ( 2 ) semi-structured interviews (n = 102) with patients, caregivers, staff, and dental providers; and ( 3 ) ethnographic observations of clinical care (n = 64) using the AEIOU framework. Data were triangulated using thematic coding and root cause analysis. Quality gaps were categorized as quantitative and qualitative gaps, and system-level challenges. Results Three categories of gaps emerged. ( 1 ) Quantitative gaps included low sealant placement (33.7%–54.6% in ages 6–9; 17.5%–43.0% in ages 10–14), inconsistent caries risk documentation (50.4%–99.6%), and high rates of untreated (23.1%–56.4%) and no new decay rates (65.9%–80.6%). ( 2 ) Qualitative gaps included limited documentation of preventive therapies, oral hygiene instruction, and nutritional counseling. Providers cited time constraints, unclear CRA protocols, and EHR usability issues. Interviews revealed unclear team roles and limited patient awareness of preventive options. ( 3 ) System-level challenges included workflow inefficiencies, fragmented responsibilities, and poor integration of CRA and preventive codes into clinical routines. Observations confirmed misalignments between documented and delivered care and missed opportunities for risk communication and same-day preventive interventions. Conclusions Substantial quality gaps persist in caries prevention and management despite institutional protocols. These gaps result from a complex interplay of systems, providers, and patient-level factors. Findings emphasize the need for coordinated data-informed strategies to improve the consistency and effectiveness of preventive care. This study highlights the value of integrating multiple data sources and user-centered methods to inform quality improvement in dental settings. caries detection/diagnosis/prevention electronic dental records caries dental informatics/bioinformatics dental public health Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Dental caries remains one of the most prevalent chronic conditions in the United States, affecting more than one in five adults with disproportionate impacts on low-income and underserved populations ( 1 ). Despite significant progress in developing and implementing preventive strategies, clinical guidelines, and evidence-based interventions, caries management in everyday practice underperforms the established standards of care ( 2 , 3 ). These gaps between recommended best practices and daily clinical practice contribute to persistent oral health disparities. Advancements in dental informatics and the widespread adoption of electronic health records (EHRs) have enabled the use of longitudinal clinical data to assess and improve the quality of oral health care through dental quality measures (DQMs). These measures aim to promote evidence-based, informed, patient-centered care ( 4 ). Our prior research has demonstrated the feasibility and validity of implementing DQMs to evaluate performance in the prevention of caries, i.e., application of fissure sealants ( 5 ), caries risk documentation and preventive interventions ( 6 ), and treatment and management of dental caries ( 7 ). For example, in one study, we used process-of-care measures and found that although 94% of patients received a caries risk assessment, the delivery of preventive therapies, including fluorides and antimicrobials, was inconsistent, with rates ranging from 56% to 94% ( 6 ). A subsequent study ( 7 ) using outcomes of care measures showed that 44% and 77% of patients had untreated caries at six months, and 20% to 35% developed new caries lesions ( 7 ). These wide variations highlight persistent clinical performance gaps in caries prevention and management. To better understand the root causes of these quality gaps, we applied the Double Diamond (DD) Model, a structured framework with four phases: Discover, Define, Develop, and Deliver (Fig. 1 ) ( 8 ). The Discover phase (divergent thinking) involves broad exploration and understanding of the problems through data collection from various sources and perspectives related to the issue under investigation. The Define phase (convergent thinking) synthesizes these findings into a focused problem statement. The subsequent phase, Develop , focuses on generating hypotheses and potential solutions to be refined during the Deliver phase, which involves peer reviews, testing, implementing workflows, and refining those solutions in practice ( 9 ). In this study, we focused on the first two phases, Discover (divergent) and Define (convergent) phases, to conduct a comprehensive problem analysis of caries prevention and management across four dental institutions. To explore the multilevel factors underlying these quality gaps, we used a triangulated, mixed-methods approach informed by principles of human-centered design and systems thinking. Our qualitative components were structured and interpreted using the AEIOU (Activities, Environments, Interactions, Objects, and Users) observational framework ( 10 ), enabling a comprehensive analysis of people, processes, tools, and environments that influence dental care delivery. Using a multi-institutional mixed-methods study approach, we collected data through: ( 1 ) structured chart reviews, ( 2 ) semi-structured interviews with patients, caregivers, providers, and staff, and ( 3 ) ethnographic clinic observations. By triangulating these data sources, we captured what was documented, reported, and observed for a deeper understanding of institutional, electronic health record (EHR) documentation and patient-level factors that drive caries management. In this paper, we present qualitative and quantitative findings from the Discover and Define phases of the DD model to map and explain current quality gaps in caries prevention and management across clinical settings. METHODS The study was conducted across four large dental care institutions: two dental schools, one large group dental practice, and one dental accountable care organization (ACO). Three of the institutions used the axiUm electronic health record (EHR) system (Exan Corp, Coquitlam, BC, Canada), while one used Epic Wisdom (Epic Systems Corporation, Verona, WI, USA). Institutional review board approval was obtained at all four sites. Guided by the Discover and Define phases of the Double Diamond (DD) Model ( 8 , 9 ) (Fig. 1 ), we employed a triangulated, mixed-methods design to identify and understand quality gaps in caries prevention and management. Three primary data sources were integrated: (A) Dental Quality Measures (DQMs) and structured chart reviews, (B) semi-structured interviews with patients, caregivers, providers, and staff, and (C) ethnographic clinical observations. A. DQMs and structured chart reviews Across the four participating dental institutions, we implemented five DQMs, all previously validated, focused on sealants ( 5 ), caries risk documentation and prevention ( 6 ), and timely treatment of dental caries and the development of new caries lesions from our dental quality measures research ( 7 ) (Table 1 ). DQM scores were calculated using R (version 4.2.0) following the standardized logic detailed in ( 5 – 7 ). Structured Query Language (SQL) scripts were developed and tailored to each institution's EHR system to extract relevant patient-level data. We queried encounters between January 1, 2019, and December 31, 2023. Patients who did not meet the numerator criteria for each measure were flagged as experiencing a potential gap in quality of care. Yet, results from the automated queries could not fully explain why patients did not meet the numerator criteria. For example, a patient may not appear in the numerator due to clinical documentation issues, patient-specific contraindications, clinical workflow interruptions, or patient preferences. Therefore, two calibrated independent reviewers at each participating institution conducted structured chart reviews (n = 2000) following a standardized set of Root Cause Analysis (RCA) based questions ( 11 ). Using SQL, we generated a list of 100 charts per quality measure at each site (n = 2000). The reviewers were researchers with experience in clinical dentistry, dental hygiene, quality measures research and implementation, and dental informatics. Responses from the chart reviews were entered into REDCap ( 12 ) and, after independent coding by two reviewers, were classified into six groups ( 1 ) financial issues, ( 2 ) failed appointments, ( 3 ) completed in subsequent years, ( 4 ) planned but not completed in the reporting year, ( 5 ) no reasons listed/unclear, and ( 6 ) never treatment planned. Table 1 Summary of Dental Quality Measures Used to Assess Caries Prevention and Management Dental Quality Measure Measure Domain Measure Description Sealants in 6–9 year olds ( 5 ) Process of care Numerator : The percentage of patients with elevated caries risk who received a sealant on permanent first molars in 6 to 9-year olds. Sealants in 10–14 year olds ( 5 ) Denominator : The percentage of patients with elevated caries risk who received a sealant on permanent first or second molars in 10 to 14-year-olds Caries Risk Assessment and Appropriateness of Care ( 6 ) Process of care Numerator : The percentage of patients who received a CRA. Process of care Denominator : The percentage of patients at elevated caries risk who received the appropriate risk-appropriate treatment. Caries Outcome of Care - New decay ( 7 ) Outcomes of care Numerator : The percentage of patients who experienced new decay within 3 years of an exam. Caries Outcome of Care – Untreated decay ( 7 ) Outcomes of care Denominator : The percentage of patients with an active caries diagnosis at an exam who still have untreated active decay at 6 months. B. Patient, Provider, and Staff Semi-Structured Interviews Interview guides were developed for three stakeholder groups: dental providers (e.g., dentists, dental hygienists, dental therapists), clinical staff (e.g., dental assistants, patient care advocates), and patients or caregivers (parents of patients). Each guide was semi-structured and organized into thematic sections aligned with the participant’s role and experience. Core domains included caries risk assessment, caries prevention and management, quality of care, communication practices, workflows, and barriers or facilitators to care delivery. While several domains were consistent across groups (e.g., perspectives on prevention), others were role-specific (e.g., documentation and team responsibilities for staff; at-home oral hygiene for patients). The full set of interview questions is presented in Appendix A, organized by the respondent group. Between February 2023 and September 2023, we completed a total of 102 individual interviews across our four clinical sites: 39 with dental providers, 35 with patients or parents, and 28 with clinical or administrative staff. All interviews were conducted virtually, with some participants opting for telephone, and each session lasted approximately 40 to 60 minutes. Interviews were facilitated by members of a dedicated research team whose interviewers are experienced clinicians and clinic leaders, ensuring both subject‑matter expertise and familiarity with day‑to‑day operational workflows. All interviews were recorded, transcribed, and analyzed thematically using ATLAS.ti software (version 23.2.1, 2023). Three reviewers independently performed initial inductive coding, followed by collaborative review sessions to assess variations, establish calibration, and develop a primary set of codes. Following this, the reviewers continued independent coding, review, and consensus to revise existing codes, incorporate additional codes, and create code groups until the codebook was finalized. Thematic analysis was conducted based on prevalence, significance, and co-occurrence of codes and code groups. Interview data informed the design of the clinical observations that followed. All interview guides used in this study are provided in Appendix A. C. Clinic Observations To complement the interviews and chart reviews, we conducted targeted clinic observations using ethnographic methods to understand real-time workflows, communication, and environmental factors influencing caries risk assessment, prevention, and management for both children and adults. These observations were conducted across all four institutions during comprehensive (D0150) and periodic (D0120) oral evaluations ( 13 ). At each site, four observation days were completed, with each session lasting approximately three hours and clinical shifts in the mornings and afternoons (n = 64 observation sessions). Observational sessions were carried out by a multidisciplinary research team of clinicians and researchers, whose combined expertise allowed them to observe and document practice‑level behaviors and workflows. Observations were guided by the AEIOU framework (described below) to ensure a structured and holistic view of the clinical work system. This framework helped categorize observations related to risk assessment, preventive interventions, procedure documentation, and treatment planning. The framework also allowed us to identify not only what occurred during dental care treatments but also how and why system-level misalignments impacted performance. Specifically: Activities included patient check-in, medical and dental history intake, caries risk assessments (CRA), and treatment planning discussions. We observed how these activities unfolded in real time and how providers engaged with documentation tasks and CRA protocols. Environment assessments focused on physical space and design, including waiting area layout, operatory space configuration, lighting, and noise levels. We noted environmental conditions that facilitated or impeded workflow, privacy, and communication clarity—particularly at check-in desks and during patient-provider consultations. Interactions captured both verbal and non-verbal communication among users. This included greetings and directions provided by front-desk staff, coordination between dental team members (e.g., dentists, assistants, hygienists), and clinical interactions with patients and caregivers. Objects referred to tools and technologies used during care delivery. These included check-in kiosks, EHR systems, CRA forms and recommendation templates, dental chairs, instruments, and monitors. Observations noted the usability of these tools and how they supported or hindered task completion. Users included all people involved in the care experience: patients, caregivers, patient-care advocates, providers, and support staff. Their behaviors, roles, and workflows were observed to understand how responsibilities were distributed and how user interactions impacted caries risk documentation and management. Findings from these observations were synthesized into journey maps (Fig. 3 ) to visualize care delivery processes, highlight breakdowns, and identify opportunities for system-level improvement. RESULTS We conducted a mixed-methods study across four large dental institutions using EHR queries, manual chart reviews, semi-structured interviews with patients, caregivers, and providers, and ethnographic clinical observations. This approach, guided by the Discover and Define phases of the Double Diamond design framework (Fig. 1 ), revealed substantial variability in the implementation and performance of five caries-related dental quality measures related to Sealants ( 5 ), Caries Risk Assessment and Appropriateness of Care ( 6 ), and Occurrence and timely treatment of dental caries ( 7 ). Below, we present triangulated findings for each dental quality measure, highlighting challenges and opportunities to improve caries prevention and management. A. Sealants Quantitative Findings Between 2019 and 2023, automated EHR queries revealed notable variation in sealant placement rates across institutions: 30.3%–54.6% for first molars (ages 6–9) and 17.5%–43.0% for second molars (ages 10–14). Manual chart reviews (n = 400) found that among eligible children aged 6–9, the most common reason for not receiving sealants was never treatment planned (36%). Among children aged 10–14, the most frequent issue was no reason listed/unclear (32%). Additionally, 24% of younger children and 14% of older children had sealant treatment planned but not completed (Fig. 2 ). Qualitative Findings Interviews and observations indicated underuse of sealants among high-risk children and occasional overuse among low-risk patients. Barriers included workflow inefficiencies, gaps in insurance coverage, and logistical constraints with same-day sealant application. Student providers often lacked confidence in sealant placement and post-operative care, particularly in high-volume or fast-paced clinical environments. Training variation and unclear supervision protocols contributed to inconsistent application across institutions. Participants described frustration with missed preventive opportunities due to insurance and clinical workflow constraints: “Unfortunately, some of the sealants, especially by the students, sometimes don't last. Then they come out. Then we get to reseal again...” – Provider “Insurance does not even cover sealants for adults... If I did a filling on that patient, it would be covered. But the sealant... the patient pays out of pocket.” – Provider “If I can do a sealant and save a cavity, I'm going to do it... If there's a tooth that's not sealed and they're moderate to high, it's getting sealed.” – Provider (See Table for additional participant quotes.) Table 2 Participant Quotations from Interviews Based on Caries Risk Assessment and Interventions Dental Quality Measure Provider/Staff/Patient Participant quotes Sealants “Unfortunately, some of the sealants, especially by the students, sometimes they don't last. Then they come out. Then we get to reseal again, so I will say that's the thing.” (Provider) “Insurance does not even cover sealants for adults. It's a big mess. So, if I did a filling on that patient, it would be covered. I have to drill it, actually drill it down, put a little material, and then it's covered. But the sealant, which I don't even have to drill, it's going to help this patient for the next five years, if not more, hopefully longer if I do it properly and well, then I've saved that tooth for a longer period of time. But guess what? The patient pays out of pocket for that sealant sometimes. It could be 50 or $60.” (Dental hygienist) “If I can do a sealant and save a cavity, I'm going to do it. And I do a lot of sealants. And sometimes, my assistants know when I walk in, if there's a tooth that's not sealed and they're moderate to high, it's getting sealed.” (Provider) Caries Risk Assessment and Appropriateness of Care “I think, again, it's [caries risk assessment is] just more laborsome work that they [residents] kind of want to [not perform and] get to the good stuff on there.” (Provider) “To be honest, I actually don't know where that is in our software. So to have it accessible and to know where it is, then we can probably utilize it a lot better.” (Provider) “But even with the recommendation, of course, some patients are very resistant of it. They could be anti-fluoride or they just don't want it due to cost.” (Provider) “I think they suggested an additional fluoride treatment, but financially, I just was like, "You know what? This is all I can spend today. I'll just be better about what I'm doing at home.” (Patient) “I think the only challenge that I would think is the cost of the toothpaste that we buy. It's getting more expensive, and insurance doesn't cover it. And I wish they did because, in the long run it saves a lot of money. But that's the only thing. I mean, for us, we have to make it a priority, but I can't imagine other families that don't have the same financial means being able to do that for multiple kids.” (Patient) Modified from: https://www.designcouncil.org.uk/our-resources/the-double-diamond/ These findings highlight systemic misalignments in sealant delivery, including financial disincentives for prevention, inconsistent provider training, and fragmented communication about caries risk and eligibility during patient visits. B. Caries Risk Assessment and Appropriateness of Care B1. Caries Risk Assessment Quantitative Findings Documentation of caries risk assessment (CRA) varied widely, ranging from 50.4% to 99.6% across institutions. Among patients identified as high risk, fluoride-based interventions—used as a proxy for appropriateness of care—were delivered to 61.1%–99.0%. Manual chart reviews revealed frequent omissions in treatment planning, documentation only in free-text notes, or institutional emphasis on restorative over preventive care. Caries incidence among patients who did not receive appropriate interventions ranged from 6% to 23% (Fig. 2 ). Qualitative Findings Interviews and observations highlighted substantial variability in CRA implementation. CRA forms were often adapted from validated tools but differed significantly across EHR systems and lacked algorithmic support for automatic risk assignment. Usability issues led many providers, especially in satellite clinics and postgraduate programs, to underuse or skip CRA forms altogether. CRA was commonly viewed as a student training requirement rather than a clinical decision-making tool. At some institutions, confusion existed about whether providers or hygienists were responsible for risk assessment and documentation. Preventive CDT codes (D0601–D0603) were inconsistently used, and workflow constraints frequently deprioritized CRA completion. B2. Appropriateness of Care: Fluoride, SDF, and Chlorhexidine Manual chart reviews and interviews identified multiple reasons for gaps in fluoride delivery: lack of treatment planning, incomplete documentation, or prioritization of restorative procedures. Cost was the most cited barrier for patients who declined fluoride treatments, especially when services were not covered by insurance. Silver diamine fluoride (SDF) was used selectively due to concerns about tooth discoloration, taste, and insurance barriers. One institution excluded it entirely from their clinical guidelines. Chlorhexidine was underutilized due to age restrictions, side effects, and limited provider awareness. Hygienists and assistants were often responsible for education and preventive applications but faced unclear protocols and time constraints. “I actually don’t know where the CRA form is in our software… if it were more accessible, we’d probably use it more.” – Provider “Sometimes patients won’t get fluoride because they can’t afford it—it’s $50 out of pocket.” – Provider “If I don’t see it in the treatment plan, I don’t bring it up. But it doesn’t mean the patient doesn’t need it.” – Assistant (See Table 2 for additional participant quotes.) C. Occurrence and timely treatment of dental caries ( 7 ). Quantitative Findings According to the EHR queries, the proportion of patients without untreated decay six months after their initial evaluation ranged from 23.1% to 56.4% across the four institutions. No New decay incidence ranged from 65.9% to 80.6%, indicating the burden of disease recurrence or progression. The manual chart reviews revealed frequent misclassification of caries risk levels, with some high-risk patients incorrectly assigned to lower risk categories, affecting up to 10% of patients at some sites. As a result, many high-risk patients did not receive recommended preventive treatments, such as prescription-strength fluoride toothpaste or chlorhexidine mouthwash, with coverage rates ranging from just 11% to 76%. In-office preventive recommendations—including nutritional counseling (CDT D1310) and oral hygiene instructions (OHI; CDT D1330)—were also inconsistently documented. In some institutions, up to 90% of high-risk patients lacked documentation of either service. Qualitative Findings Patient interviews revealed general confusion around basic oral hygiene practices, including toothbrush and toothpaste selection, flossing frequency, and appropriate use of mouthwash. These findings were consistent with observational data, which identified multiple barriers to compliance with traditional oral hygiene preventive protocols, such as low oral health literacy and competing life demands. Such contextual factors often went undocumented in the patient EHR charts but had a direct impact on patient compliance and clinical outcomes. “I wish they had told me exactly what kind of toothpaste to buy. I didn’t know prescription toothpaste was even a thing.” – Patient “We give the instructions, but if it’s not in the treatment plan, it doesn’t get followed up.” – Provider “Some of my patients don’t floss because they don’t know how—others because they don’t think it matters.” – Hygienist (See Table 2 for additional participant quotes.) Systems-Level Insights Our results suggest a complex interplay between the clinical environment, EHR tools, and team communication. For example, lack of designated spaces for private counseling, limited access to educational materials, and unclear handoffs between providers and hygienists contributed to breakdowns in preventive care delivery. These findings emphasize that quality gaps in caries prevention also include system issues and are not solely behavioral or clinically driven. Cross-Cutting Themes Across Measures Several recurring themes emerged across all five quality measures. Inconsistent documentation, particularly around CRA coding, fluoride delivery, and preventive counseling, was widespread. Role ambiguity among providers, hygienists, and assistants led to gaps in care delivery and communication. Workflow inefficiencies and EHR usability issues limited the consistent application of preventive protocols. From the patient's perspective, financial barriers and limited oral health literacy influenced treatment acceptance. These patterns were further illustrated through participant quotes presented in Table 2 , highlighting how both system-based and human factors impact the reliability and consistency of caries prevention methods. DISCUSSION This multi-institutional mixed-methods research study systematically mapped quality gaps in caries prevention and management across four large U.S. dental institutions. Substantial variability in sealant placement, fluoride delivery, caries risk documentation, and caries outcomes was observed, driven by intersecting system-, provider-, and patient-level factors. Inconsistent documentation, particularly around CRA codes, preventive CDT codes, and counseling, interfered with actual care delivery and limited the applicability of dental quality metrics, consistent with other healthcare fields ( 14 ). Role ambiguity among providers, hygienists, and assistants created uncertainty around task ownership, especially regarding CRA completion and patient education. Workflow bottlenecks, time constraints, and cumbersome EHR interfaces further undermined protocol adherence. On the patient side, financial barriers and limited oral health literacy shaped treatment acceptance and follow-through. These themes, illustrated in Table 2 , suggest that quality gaps are mostly system-based rather than isolated incidents of noncompliance. Our findings are consistent with national data showing that sealant placement rates remain below public health goals ( 1 , 5 ). We also found that CRA was commonly perceived as an “academic requirement” primarily for students, a finding consistently reported in studies from other academic settings ( 15 , 16 ). Despite institutional policies supporting risk-based dental care, CRA completion was often bypassed due to usability barriers or deprioritized in favor of restorative procedures. This reinforces prior evidence that risk assessment, though clinically endorsed, is inconsistently implemented in real-world settings ( 17 ). The use of the Double Diamond design framework helped us distinguish between problem discovery—quantitative identification of quality gaps—and problem definition—qualitative exploration of their underlying causes ( 8 , 9 ). Findings from this study suggest several practical implications. First, integrating decision support tools into EHRs—such as auto-populated CRA forms and clinical reminders tied to caries risk—could improve consistency in preventive care delivery. Second, clarifying standing orders so that hygienists and assistants can complete CRA, apply fluoride varnish, and document patient education may enhance role clarity and reduce missed opportunities. Third, expanding insurance reimbursement to cover sealants and fluoride across all ages, and aligning incentives with documentation completeness, could mitigate the financial disincentives frequently cited by both patients and providers. Fourth, targeted education tailored to provider roles—including students, residents, and clinical staff—may address confidence gaps and reinforce evidence-based protocols. Finally, the development of culturally and literacy-appropriate communication aids, combined with techniques like teach-back, may help overcome the patient-level barriers identified through interviews and observations. This study has several strengths, including the integration of validated dental quality measures, triangulation of four data sources, and the use of human-centered design and systems frameworks to interpret findings. However, there are limitations. Manual chart reviews, while structured, are subject to abstraction bias. Institutional customization of EHR systems may affect generalizability. The cross-sectional nature of interviews and observations may not fully capture dynamic or seasonal shifts in workflow. The presence of observers may have altered clinician behavior, although this potential Hawthorne effect was mitigated through corroboration with EHR and interview data ( 18 ). Future research should focus on prospective trials evaluating the impact of integrated decision-support tools and team-based care models on preventive quality measure performance. Economic evaluations are needed to quantify cost savings associated with reduced restorative burden from improved prevention. In parallel, co-design efforts with patients and families could inform the development of communication tools that are contextually relevant and health-literate. CONCLUSIONS This mixed-methods study advances dental quality measure research by providing a comprehensive, multi-level view of the operational and contextual drivers behind persistent quality gaps in caries prevention and management across distinct dental institutions. Through the innovative application of the Double Diamond framework and triangulated methods integrating chart reviews, interviews, and clinical observations, we identified systems-level barriers that contribute to inconsistent delivery of evidence-based preventive care. Findings underscore the need for coordinated interdisciplinary efforts to address these gaps. Stakeholders, including dental professionals, practice leaders, policymakers, and health informatics experts, must collaborate to implement targeted solutions. Leveraging real-time data, standardized quality measures, and embedded clinical decision tools offers a promising path toward improving the consistency and effectiveness of preventive services. This study demonstrates the value of integrating multiple data sources and user-centered approaches to inform quality improvement efforts. Such approaches can bridge the gap between evidence and routine practice, enhancing the delivery of patient-centered, preventive oral health care in real-world settings. Declarations This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of UTHealth Houston (approval number: HSC-DB-21-0471), and corresponding approvals were secured from all participating institutions. All participants, including patients, caregivers, providers, and staff who were observed or interviewed, provided written informed consent prior to participation. Consent for publication Not applicable Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to institutional and ethical restrictions related to patient and participant privacy. The data include protected health information derived from electronic health records and interview transcripts containing potentially identifiable details. De-identified and aggregated data that support the findings of this study may be made available from the corresponding author on reasonable request and with permission from the participating institutions’ Institutional Review Boards. Competing interests “The Authors declare that there is no conflict of interest.’ Funding: Research reported in this publication was supported in part by an award 5R01DE024166-10 from the National Institute of Dental and Craniofacial Research, National Institutes of Health. Authors' contributions Suhasini Bangar : Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Project administration. Janelle Urata : Methodology, Data curation, Investigation, Writing – review & editing. Oluwabunmi Tokede : Methodology, Data interpretation, Writing – review & editing. Sayali Tungare : Data analysis, Writing – review & editing. Heather Weidner : Data analysis, Writing – review & editing. Aaron Truong : Data analysis, Writing – review & editing. Urvi Mehta : Data analysis, Writing – review & editing. Alfa-Ibrahim Yansane : Data interpretation, Writing – review & editing. Gregory W. Olson : Data interpretation, Writing – review & editing. Emily W. Sedlock : Data interpretation, Writing – review & editing. Donald Worley : Data acquisition, Data interpretation, Writing – review & editing. Joanna Mullins : Data interpretation, Writing – review & editing. Ryan Brandon : Data acquisition, Data analysis, Writing – review & editing. D. Brad Rindal : Data interpretation, Writing – review & editing. Todd Johnson : Data interpretation, Writing – review & editing. Krishna Kumar Kookal : Data acquisition, Writing – review & editing. Nicholas Skourtes : Data interpretation, Writing – review & editing. Swaroop Gantela : Data interpretation, Writing – review & editing. Heiko Spallek : Data interpretation, Writing – review & editing. Joel White : Data interpretation, Writing – review & editing. Elsbeth Kalenderian : Formal analysis, Data interpretation, Writing – review & editing. Muhammad Walji : Conceptualization, Methodology, Data analysis, Writing – review & editing, Supervision. Ana Neumann : Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Supervision. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgments: Research reported in this publication was supported in part by an award 5R01DE024166-10 from the National Institute of Dental and Craniofacial Research, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. References Bashir NZ. Update on the prevalence of untreated caries in the US adult population, 2017–2020. J Am Dent Assoc. 2022;153(4):300–8. Fontana M, Gonzalez-Cabezas C, Tenuta LMA. Evidence-based approaches and considerations for nonrestorative treatments within modern caries management: Integrating science into practice. J Am Dent Assoc. 2024;155(12):1000–11. Featherstone JDB, Crystal YO, Alston P, Chaffee BW, Domejean S, Rechmann P, et al. Evidence-Based Caries Management for All Ages-Practical Guidelines. Front Oral Health. 2021;2:657518. Baadoudi F, Trescher A, Duijster D, Maskrey N, Gabel F, van der Heijden GJ, et al. 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Supplementary Files AppendixA.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 25 Dec, 2025 Reviewers agreed at journal 24 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor invited by journal 14 Nov, 2025 Editor assigned by journal 13 Nov, 2025 Submission checks completed at journal 13 Nov, 2025 First submitted to journal 27 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7963779","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561197907,"identity":"afc01d9b-7df6-4955-a65f-7e8feaea7920","order_by":0,"name":"Suhasini Bangar","email":"","orcid":"","institution":"The University of Texas Health Science Center McWilliams School of Biomedical Informatics","correspondingAuthor":false,"prefix":"","firstName":"Suhasini","middleName":"","lastName":"Bangar","suffix":""},{"id":561197908,"identity":"381f237a-4f16-484a-a266-d997009ff283","order_by":1,"name":"Janelle Urata","email":"","orcid":"","institution":"University of California San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Janelle","middleName":"","lastName":"Urata","suffix":""},{"id":561197909,"identity":"66def270-62ee-4e1a-924a-738ce7003e66","order_by":2,"name":"Oluwabunmi Tokede","email":"","orcid":"","institution":"The University of Texas Health Science Center at Houston School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Oluwabunmi","middleName":"","lastName":"Tokede","suffix":""},{"id":561197910,"identity":"7a30b5d9-fd79-4ebe-94c3-9c6452dfa4e0","order_by":3,"name":"Sayali Tungare","email":"","orcid":"","institution":"The University of Texas Health Science Center McWilliams School of Biomedical Informatics","correspondingAuthor":false,"prefix":"","firstName":"Sayali","middleName":"","lastName":"Tungare","suffix":""},{"id":561197911,"identity":"980d5c32-162f-4788-9f3b-521f32026096","order_by":4,"name":"Heather Weidner","email":"","orcid":"","institution":"HealthPartners Institute","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Weidner","suffix":""},{"id":561197912,"identity":"84fc5915-b155-409c-b0e1-25eb424619f7","order_by":5,"name":"Aaron Truong","email":"","orcid":"","institution":"Willamette Dental","correspondingAuthor":false,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Truong","suffix":""},{"id":561197913,"identity":"13fc5137-ff4a-4d2d-9f8a-a67e41eaade5","order_by":6,"name":"Urvi Mehta","email":"","orcid":"","institution":"University of Alabama at Birmingham, School of Dentistry,","correspondingAuthor":false,"prefix":"","firstName":"Urvi","middleName":"","lastName":"Mehta","suffix":""},{"id":561197914,"identity":"eacf62b5-60dc-4055-9100-be86894fd9e9","order_by":7,"name":"Alfa-Ibrahim Yansane","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Alfa-Ibrahim","middleName":"","lastName":"Yansane","suffix":""},{"id":561197915,"identity":"fcb5d730-1573-403e-9019-be9bf9a55b4b","order_by":8,"name":"Gregory Olson","email":"","orcid":"","institution":"The University of Texas Health Science Center at Houston School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Olson","suffix":""},{"id":561197916,"identity":"769d69fc-a47e-4679-89b5-aa5eb673214b","order_by":9,"name":"Donald Worley","email":"","orcid":"","institution":"The University of Texas Health Science Center at Houston School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Donald","middleName":"","lastName":"Worley","suffix":""},{"id":561197917,"identity":"902f98b3-4f45-45c0-b031-42cbd3d74204","order_by":10,"name":"Emily W. 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12:26:12","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100730,"visible":true,"origin":"","legend":"","description":"","filename":"6f3b1d4a211f448c887e537b8a698a401structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/0ac5fa062fea39629ec552a2.xml"},{"id":98777621,"identity":"abb8aed7-8414-48c2-a5c3-bf0aa1c70c78","added_by":"auto","created_at":"2025-12-22 12:28:12","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127633,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/82c03a13ead3a6aa71d367f2.html"},{"id":98777162,"identity":"24c8b216-b27d-45ee-bc39-67adeadc863d","added_by":"auto","created_at":"2025-12-22 12:25:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":132794,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eList of Contributing Factors Identified from Chart Reviews for Patients who did not meet the Quality Measure Criteria\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/97ce14469c02147578386160.png"},{"id":98779848,"identity":"71d06bbd-cf96-400e-875a-8c12c78ea8fa","added_by":"auto","created_at":"2025-12-22 12:30:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Double Diamond Design Framework for Identifying and Addressing Quality Gaps in Caries Prevention and Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eModified from: https://www.designcouncil.org.uk/our-resources/the-double-diamond/\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/9e80fc19279b6fe371719fbd.png"},{"id":98778528,"identity":"a64b8c9a-fe69-4416-8b11-cf680eba77ba","added_by":"auto","created_at":"2025-12-22 12:29:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":465096,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExample of a Journey Map Analysis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/25e4ac1f14b79adfc3a0a1ef.png"},{"id":98784008,"identity":"4830abde-b646-4e6f-a191-c6ed2ac07939","added_by":"auto","created_at":"2025-12-22 12:42:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1781419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/2a2e8204-e493-47a6-8416-a330cbfb7689.pdf"},{"id":98778679,"identity":"f26a34ee-4d16-411d-8e25-55dd61ccbcb1","added_by":"auto","created_at":"2025-12-22 12:29:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18157,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-7963779/v1/f996d189dc42621381d66b58.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Identifying Gaps in Caries Prevention and Management: A Multi-Institutional Mixed-Methods Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDental caries remains one of the most prevalent chronic conditions in the United States, affecting more than one in five adults with disproportionate impacts on low-income and underserved populations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite significant progress in developing and implementing preventive strategies, clinical guidelines, and evidence-based interventions, caries management in everyday practice underperforms the established standards of care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These gaps between recommended best practices and daily clinical practice contribute to persistent oral health disparities.\u003c/p\u003e \u003cp\u003eAdvancements in dental informatics and the widespread adoption of electronic health records (EHRs) have enabled the use of longitudinal clinical data to assess and improve the quality of oral health care through dental quality measures (DQMs). These measures aim to promote evidence-based, informed, patient-centered care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Our prior research has demonstrated the feasibility and validity of implementing DQMs to evaluate performance in the prevention of caries, i.e., application of fissure sealants (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), caries risk documentation and preventive interventions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and treatment and management of dental caries (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor example, in one study, we used process-of-care measures and found that although 94% of patients received a caries risk assessment, the delivery of preventive therapies, including fluorides and antimicrobials, was inconsistent, with rates ranging from 56% to 94% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A subsequent study (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) using outcomes of care measures showed that 44% and 77% of patients had untreated caries at six months, and 20% to 35% developed new caries lesions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These wide variations highlight persistent clinical performance gaps in caries prevention and management.\u003c/p\u003e \u003cp\u003eTo better understand the root causes of these quality gaps, we applied the Double Diamond (DD) Model, a structured framework with four phases: Discover, Define, Develop, and Deliver (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The \u003cem\u003eDiscover\u003c/em\u003e phase (divergent thinking) involves broad exploration and understanding of the problems through data collection from various sources and perspectives related to the issue under investigation. The \u003cem\u003eDefine\u003c/em\u003e phase (convergent thinking) synthesizes these findings into a focused problem statement. The subsequent phase, \u003cem\u003eDevelop\u003c/em\u003e, focuses on generating hypotheses and potential solutions to be refined during the \u003cem\u003eDeliver\u003c/em\u003e phase, which involves peer reviews, testing, implementing workflows, and refining those solutions in practice (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In this study, we focused on the first two phases, Discover (divergent) and Define (convergent) phases, to conduct a comprehensive problem analysis of caries prevention and management across four dental institutions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo explore the multilevel factors underlying these quality gaps, we used a triangulated, mixed-methods approach informed by principles of human-centered design and systems thinking. Our qualitative components were structured and interpreted using the AEIOU (Activities, Environments, Interactions, Objects, and Users) observational framework (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), enabling a comprehensive analysis of people, processes, tools, and environments that influence dental care delivery.\u003c/p\u003e \u003cp\u003eUsing a multi-institutional mixed-methods study approach, we collected data through: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) structured chart reviews, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) semi-structured interviews with patients, caregivers, providers, and staff, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) ethnographic clinic observations. By triangulating these data sources, we captured what was documented, reported, and observed for a deeper understanding of institutional, electronic health record (EHR) documentation and patient-level factors that drive caries management. In this paper, we present qualitative and quantitative findings from the Discover and Define phases of the DD model to map and explain current quality gaps in caries prevention and management across clinical settings.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe study was conducted across four large dental care institutions: two dental schools, one large group dental practice, and one dental accountable care organization (ACO). Three of the institutions used the axiUm electronic health record (EHR) system (Exan Corp, Coquitlam, BC, Canada), while one used Epic Wisdom (Epic Systems Corporation, Verona, WI, USA). Institutional review board approval was obtained at all four sites. Guided by the Discover and Define phases of the Double Diamond (DD) Model (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), we employed a triangulated, mixed-methods design to identify and understand quality gaps in caries prevention and management.\u003c/p\u003e \u003cp\u003eThree primary data sources were integrated: (A) Dental Quality Measures (DQMs) and structured chart reviews, (B) semi-structured interviews with patients, caregivers, providers, and staff, and (C) ethnographic clinical observations.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cem\u003eA. DQMs and structured chart reviews\u003c/em\u003e\u003c/h2\u003e \u003cp\u003eAcross the four participating dental institutions, we implemented five DQMs, all previously validated, focused on sealants (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), caries risk documentation and prevention (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and timely treatment of dental caries and the development of new caries lesions from our dental quality measures research (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). DQM scores were calculated using R (version 4.2.0) following the standardized logic detailed in (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Structured Query Language (SQL) scripts were developed and tailored to each institution's EHR system to extract relevant patient-level data. We queried encounters between January 1, 2019, and December 31, 2023. Patients who did not meet the numerator criteria for each measure were flagged as experiencing a potential gap in quality of care. Yet, results from the automated queries could not fully explain why patients did not meet the numerator criteria. For example, a patient may not appear in the numerator due to clinical documentation issues, patient-specific contraindications, clinical workflow interruptions, or patient preferences. Therefore, two calibrated independent reviewers at each participating institution conducted structured chart reviews (n\u0026thinsp;=\u0026thinsp;2000) following a standardized set of Root Cause Analysis (RCA) based questions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Using SQL, we generated a list of 100 charts per quality measure at each site (n\u0026thinsp;=\u0026thinsp;2000). The reviewers were researchers with experience in clinical dentistry, dental hygiene, quality measures research and implementation, and dental informatics. Responses from the chart reviews were entered into REDCap (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and, after independent coding by two reviewers, were classified into six groups (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) financial issues, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) failed appointments, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) completed in subsequent years, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) planned but not completed in the reporting year, (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) no reasons listed/unclear, and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) never treatment planned.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Dental Quality Measures Used to Assess Caries Prevention and Management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental Quality Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasure Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeasure Description\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSealants in 6\u0026ndash;9 year olds (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProcess of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNumerator\u003c/em\u003e: The percentage of patients with elevated caries risk who received a sealant on permanent first molars in 6 to 9-year olds.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSealants in 10\u0026ndash;14 year olds (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eDenominator\u003c/em\u003e: The percentage of patients with elevated caries risk who received a sealant on permanent first or second molars in 10 to 14-year-olds\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCaries Risk Assessment and Appropriateness of Care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProcess of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNumerator\u003c/em\u003e: The percentage of patients who received a CRA.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProcess of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eDenominator\u003c/em\u003e: The percentage of patients at elevated caries risk who received the appropriate risk-appropriate treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaries Outcome of Care - New decay (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcomes of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNumerator\u003c/em\u003e: The percentage of patients who experienced new decay within 3 years of an exam.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaries Outcome of Care \u0026ndash; Untreated decay (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcomes of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eDenominator\u003c/em\u003e: The percentage of patients with an active caries diagnosis at an exam who still have untreated active decay at 6 months.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eB. Patient, Provider, and Staff Semi-Structured Interviews\u003c/h3\u003e\n\u003cp\u003eInterview guides were developed for three stakeholder groups: dental providers (e.g., dentists, dental hygienists, dental therapists), clinical staff (e.g., dental assistants, patient care advocates), and patients or caregivers (parents of patients). Each guide was semi-structured and organized into thematic sections aligned with the participant\u0026rsquo;s role and experience. Core domains included caries risk assessment, caries prevention and management, quality of care, communication practices, workflows, and barriers or facilitators to care delivery. While several domains were consistent across groups (e.g., perspectives on prevention), others were role-specific (e.g., documentation and team responsibilities for staff; at-home oral hygiene for patients). The full set of interview questions is presented in Appendix A, organized by the respondent group.\u003c/p\u003e \u003cp\u003eBetween February 2023 and September 2023, we completed a total of 102 individual interviews across our four clinical sites: 39 with dental providers, 35 with patients or parents, and 28 with clinical or administrative staff. All interviews were conducted virtually, with some participants opting for telephone, and each session lasted approximately 40 to 60 minutes. Interviews were facilitated by members of a dedicated research team whose interviewers are experienced clinicians and clinic leaders, ensuring both subject‑matter expertise and familiarity with day‑to‑day operational workflows.\u003c/p\u003e \u003cp\u003eAll interviews were recorded, transcribed, and analyzed thematically using ATLAS.ti software (version 23.2.1, 2023). Three reviewers independently performed initial inductive coding, followed by collaborative review sessions to assess variations, establish calibration, and develop a primary set of codes. Following this, the reviewers continued independent coding, review, and consensus to revise existing codes, incorporate additional codes, and create code groups until the codebook was finalized. Thematic analysis was conducted based on prevalence, significance, and co-occurrence of codes and code groups. Interview data informed the design of the clinical observations that followed. All interview guides used in this study are provided in Appendix A.\u003c/p\u003e\n\u003ch3\u003eC. Clinic Observations\u003c/h3\u003e\n\u003cp\u003eTo complement the interviews and chart reviews, we conducted targeted clinic observations using ethnographic methods to understand real-time workflows, communication, and environmental factors influencing caries risk assessment, prevention, and management for both children and adults. These observations were conducted across all four institutions during comprehensive (D0150) and periodic (D0120) oral evaluations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt each site, four observation days were completed, with each session lasting approximately three hours and clinical shifts in the mornings and afternoons (n\u0026thinsp;=\u0026thinsp;64 observation sessions). Observational sessions were carried out by a multidisciplinary research team of clinicians and researchers, whose combined expertise allowed them to observe and document practice‑level behaviors and workflows. Observations were guided by the AEIOU framework (described below) to ensure a structured and holistic view of the clinical work system. This framework helped categorize observations related to risk assessment, preventive interventions, procedure documentation, and treatment planning. The framework also allowed us to identify not only what occurred during dental care treatments but also how and why system-level misalignments impacted performance.\u003c/p\u003e \u003cp\u003eSpecifically:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eActivities\u003c/em\u003e included patient check-in, medical and dental history intake, caries risk assessments (CRA), and treatment planning discussions. We observed how these activities unfolded in real time and how providers engaged with documentation tasks and CRA protocols.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eEnvironment\u003c/em\u003e assessments focused on physical space and design, including waiting area layout, operatory space configuration, lighting, and noise levels. We noted environmental conditions that facilitated or impeded workflow, privacy, and communication clarity\u0026mdash;particularly at check-in desks and during patient-provider consultations.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eInteractions\u003c/em\u003e captured both verbal and non-verbal communication among users. This included greetings and directions provided by front-desk staff, coordination between dental team members (e.g., dentists, assistants, hygienists), and clinical interactions with patients and caregivers.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eObjects\u003c/em\u003e referred to tools and technologies used during care delivery. These included check-in kiosks, EHR systems, CRA forms and recommendation templates, dental chairs, instruments, and monitors. Observations noted the usability of these tools and how they supported or hindered task completion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eUsers\u003c/em\u003e included all people involved in the care experience: patients, caregivers, patient-care advocates, providers, and support staff. Their behaviors, roles, and workflows were observed to understand how responsibilities were distributed and how user interactions impacted caries risk documentation and management.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eFindings from these observations were synthesized into journey maps (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) to visualize care delivery processes, highlight breakdowns, and identify opportunities for system-level improvement.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe conducted a mixed-methods study across four large dental institutions using EHR queries, manual chart reviews, semi-structured interviews with patients, caregivers, and providers, and ethnographic clinical observations. This approach, guided by the Discover and Define phases of the Double Diamond design framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), revealed substantial variability in the implementation and performance of five caries-related dental quality measures related to Sealants (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), Caries Risk Assessment and Appropriateness of Care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and Occurrence and timely treatment of dental caries (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Below, we present triangulated findings for each dental quality measure, highlighting challenges and opportunities to improve caries prevention and management.\u003c/p\u003e\n\u003ch3\u003eA. Sealants\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cp\u003eBetween 2019 and 2023, automated EHR queries revealed notable variation in sealant placement rates across institutions: 30.3%\u0026ndash;54.6% for first molars (ages 6\u0026ndash;9) and 17.5%\u0026ndash;43.0% for second molars (ages 10\u0026ndash;14). Manual chart reviews (n\u0026thinsp;=\u0026thinsp;400) found that among eligible children aged 6\u0026ndash;9, the most common reason for not receiving sealants was \u003cem\u003enever treatment planned\u003c/em\u003e (36%). Among children aged 10\u0026ndash;14, the most frequent issue was \u003cem\u003eno reason listed/unclear\u003c/em\u003e (32%). Additionally, 24% of younger children and 14% of older children had sealant treatment planned but not completed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Findings\u003c/h3\u003e\n\u003cp\u003eInterviews and observations indicated underuse of sealants among high-risk children and occasional overuse among low-risk patients. Barriers included workflow inefficiencies, gaps in insurance coverage, and logistical constraints with same-day sealant application. Student providers often lacked confidence in sealant placement and post-operative care, particularly in high-volume or fast-paced clinical environments.\u003c/p\u003e \u003cp\u003eTraining variation and unclear supervision protocols contributed to inconsistent application across institutions. Participants described frustration with missed preventive opportunities due to insurance and clinical workflow constraints:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, some of the sealants, especially by the students, sometimes don't last. Then they come out. Then we get to reseal again...\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Insurance does not even cover sealants for adults... If I did a filling on that patient, it would be covered. But the sealant... the patient pays out of pocket.\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If I can do a sealant and save a cavity, I'm going to do it... If there's a tooth that's not sealed and they're moderate to high, it's getting sealed.\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e\n\u003ch3\u003e(See Table for additional participant quotes.)\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Quotations from Interviews Based on Caries Risk Assessment and Interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental Quality Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvider/Staff/Patient Participant quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSealants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Unfortunately, some of the sealants, especially by the students, sometimes they don't last. Then they come out. Then we get to reseal again, so I will say that's the thing.\u0026rdquo; (Provider)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Insurance does not even cover sealants for adults. It's a big mess. So, if I did a filling on that patient, it would be covered. I have to drill it, actually drill it down, put a little material, and then it's covered. But the sealant, which I don't even have to drill, it's going to help this patient for the next five years, if not more, hopefully longer if I do it properly and well, then I've saved that tooth for a longer period of time. But guess what? The patient pays out of pocket for that sealant sometimes. It could be 50 or $60.\u0026rdquo; (Dental hygienist)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;If I can do a sealant and save a cavity, I'm going to do it. And I do a lot of sealants. And sometimes, my assistants know when I walk in, if there's a tooth that's not sealed and they're moderate to high, it's getting sealed.\u0026rdquo; (Provider)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCaries Risk Assessment and Appropriateness of Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think, again, it's [caries risk assessment is] just more laborsome work that they [residents] kind of want to [not perform and] get to the good stuff on there.\u0026rdquo; (Provider)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;To be honest, I actually don't know where that is in our software. So to have it accessible and to know where it is, then we can probably utilize it a lot better.\u0026rdquo; (Provider)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;But even with the recommendation, of course, some patients are very resistant of it. They could be anti-fluoride or they just don't want it due to cost.\u0026rdquo; (Provider)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think they suggested an additional fluoride treatment, but financially, I just was like, \"You know what? This is all I can spend today. I'll just be better about what I'm doing at home.\u0026rdquo; (Patient)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think the only challenge that I would think is the cost of the toothpaste that we buy. It's getting more expensive, and insurance doesn't cover it. And I wish they did because, in the long run it saves a lot of money. But that's the only thing. I mean, for us, we have to make it a priority, but I can't imagine other families that don't have the same financial means being able to do that for multiple kids.\u0026rdquo; (Patient)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eModified from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.designcouncil.org.uk/our-resources/the-double-diamond/\u003c/span\u003e\u003cspan address=\"https://www.designcouncil.org.uk/our-resources/the-double-diamond/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese findings highlight systemic misalignments in sealant delivery, including financial disincentives for prevention, inconsistent provider training, and fragmented communication about caries risk and eligibility during patient visits.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eB. Caries Risk Assessment and Appropriateness of Care\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eB1. Caries Risk Assessment\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section4\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cp\u003eDocumentation of caries risk assessment (CRA) varied widely, ranging from 50.4% to 99.6% across institutions. Among patients identified as high risk, fluoride-based interventions\u0026mdash;used as a proxy for appropriateness of care\u0026mdash;were delivered to 61.1%\u0026ndash;99.0%. Manual chart reviews revealed frequent omissions in treatment planning, documentation only in free-text notes, or institutional emphasis on restorative over preventive care. Caries incidence among patients who did not receive appropriate interventions ranged from 6% to 23% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Findings\u003c/h2\u003e \u003cp\u003eInterviews and observations highlighted substantial variability in CRA implementation. CRA forms were often adapted from validated tools but differed significantly across EHR systems and lacked algorithmic support for automatic risk assignment. Usability issues led many providers, especially in satellite clinics and postgraduate programs, to underuse or skip CRA forms altogether.\u003c/p\u003e \u003cp\u003eCRA was commonly viewed as a student training requirement rather than a clinical decision-making tool. At some institutions, confusion existed about whether providers or hygienists were responsible for risk assessment and documentation. Preventive CDT codes (D0601\u0026ndash;D0603) were inconsistently used, and workflow constraints frequently deprioritized CRA completion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eB2. Appropriateness of Care: Fluoride, SDF, and Chlorhexidine\u003c/h2\u003e \u003cp\u003eManual chart reviews and interviews identified multiple reasons for gaps in fluoride delivery: lack of treatment planning, incomplete documentation, or prioritization of restorative procedures. Cost was the most cited barrier for patients who declined fluoride treatments, especially when services were not covered by insurance.\u003c/p\u003e \u003cp\u003eSilver diamine fluoride (SDF) was used selectively due to concerns about tooth discoloration, taste, and insurance barriers. One institution excluded it entirely from their clinical guidelines. Chlorhexidine was underutilized due to age restrictions, side effects, and limited provider awareness. Hygienists and assistants were often responsible for education and preventive applications but faced unclear protocols and time constraints.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I actually don\u0026rsquo;t know where the CRA form is in our software\u0026hellip; if it were more accessible, we\u0026rsquo;d probably use it more.\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes patients won\u0026rsquo;t get fluoride because they can\u0026rsquo;t afford it\u0026mdash;it\u0026rsquo;s $50 out of pocket.\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If I don\u0026rsquo;t see it in the treatment plan, I don\u0026rsquo;t bring it up. But it doesn\u0026rsquo;t mean the patient doesn\u0026rsquo;t need it.\u0026rdquo;\u003c/em\u003e \u0026ndash; Assistant\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e(See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for additional participant quotes.)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eC. Occurrence and timely treatment of dental caries\u003c/b\u003e (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cp\u003eAccording to the EHR queries, the proportion of patients without untreated decay six months after their initial evaluation ranged from 23.1% to 56.4% across the four institutions. No New decay incidence ranged from 65.9% to 80.6%, indicating the burden of disease recurrence or progression. The manual chart reviews revealed frequent misclassification of caries risk levels, with some high-risk patients incorrectly assigned to lower risk categories, affecting up to 10% of patients at some sites. As a result, many high-risk patients did not receive recommended preventive treatments, such as prescription-strength fluoride toothpaste or chlorhexidine mouthwash, with coverage rates ranging from just 11% to 76%. In-office preventive recommendations\u0026mdash;including nutritional counseling (CDT D1310) and oral hygiene instructions (OHI; CDT D1330)\u0026mdash;were also inconsistently documented. In some institutions, up to 90% of high-risk patients lacked documentation of either service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Findings\u003c/h2\u003e \u003cp\u003e Patient interviews revealed general confusion around basic oral hygiene practices, including toothbrush and toothpaste selection, flossing frequency, and appropriate use of mouthwash. These findings were consistent with observational data, which identified multiple barriers to compliance with traditional oral hygiene preventive protocols, such as low oral health literacy and competing life demands. Such contextual factors often went undocumented in the patient EHR charts but had a direct impact on patient compliance and clinical outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I wish they had told me exactly what kind of toothpaste to buy. I didn\u0026rsquo;t know prescription toothpaste was even a thing.\u0026rdquo;\u003c/em\u003e \u0026ndash; Patient\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We give the instructions, but if it\u0026rsquo;s not in the treatment plan, it doesn\u0026rsquo;t get followed up.\u0026rdquo;\u003c/em\u003e \u0026ndash; Provider\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some of my patients don\u0026rsquo;t floss because they don\u0026rsquo;t know how\u0026mdash;others because they don\u0026rsquo;t think it matters.\u0026rdquo;\u003c/em\u003e \u0026ndash; Hygienist\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e(See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for additional participant quotes.)\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eSystems-Level Insights\u003c/h2\u003e \u003cp\u003eOur results suggest a complex interplay between the clinical environment, EHR tools, and team communication. For example, lack of designated spaces for private counseling, limited access to educational materials, and unclear handoffs between providers and hygienists contributed to breakdowns in preventive care delivery. These findings emphasize that quality gaps in caries prevention also include system issues and are not solely behavioral or clinically driven.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCross-Cutting Themes Across Measures\u003c/h2\u003e \u003cp\u003eSeveral recurring themes emerged across all five quality measures. Inconsistent documentation, particularly around CRA coding, fluoride delivery, and preventive counseling, was widespread. Role ambiguity among providers, hygienists, and assistants led to gaps in care delivery and communication. Workflow inefficiencies and EHR usability issues limited the consistent application of preventive protocols. From the patient's perspective, financial barriers and limited oral health literacy influenced treatment acceptance. These patterns were further illustrated through participant quotes presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, highlighting how both system-based and human factors impact the reliability and consistency of caries prevention methods.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis multi-institutional mixed-methods research study systematically mapped quality gaps in caries prevention and management across four large U.S. dental institutions. Substantial variability in sealant placement, fluoride delivery, caries risk documentation, and caries outcomes was observed, driven by intersecting system-, provider-, and patient-level factors. Inconsistent documentation, particularly around CRA codes, preventive CDT codes, and counseling, interfered with actual care delivery and limited the applicability of dental quality metrics, consistent with other healthcare fields (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRole ambiguity among providers, hygienists, and assistants created uncertainty around task ownership, especially regarding CRA completion and patient education. Workflow bottlenecks, time constraints, and cumbersome EHR interfaces further undermined protocol adherence. On the patient side, financial barriers and limited oral health literacy shaped treatment acceptance and follow-through. These themes, illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, suggest that quality gaps are mostly system-based rather than isolated incidents of noncompliance.\u003c/p\u003e \u003cp\u003eOur findings are consistent with national data showing that sealant placement rates remain below public health goals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). We also found that CRA was commonly perceived as an \u0026ldquo;academic requirement\u0026rdquo; primarily for students, a finding consistently reported in studies from other academic settings (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite institutional policies supporting risk-based dental care, CRA completion was often bypassed due to usability barriers or deprioritized in favor of restorative procedures. This reinforces prior evidence that risk assessment, though clinically endorsed, is inconsistently implemented in real-world settings (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe use of the Double Diamond design framework helped us distinguish between problem discovery\u0026mdash;quantitative identification of quality gaps\u0026mdash;and problem definition\u0026mdash;qualitative exploration of their underlying causes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFindings from this study suggest several practical implications. First, integrating decision support tools into EHRs\u0026mdash;such as auto-populated CRA forms and clinical reminders tied to caries risk\u0026mdash;could improve consistency in preventive care delivery. Second, clarifying standing orders so that hygienists and assistants can complete CRA, apply fluoride varnish, and document patient education may enhance role clarity and reduce missed opportunities. Third, expanding insurance reimbursement to cover sealants and fluoride across all ages, and aligning incentives with documentation completeness, could mitigate the financial disincentives frequently cited by both patients and providers. Fourth, targeted education tailored to provider roles\u0026mdash;including students, residents, and clinical staff\u0026mdash;may address confidence gaps and reinforce evidence-based protocols. Finally, the development of culturally and literacy-appropriate communication aids, combined with techniques like teach-back, may help overcome the patient-level barriers identified through interviews and observations.\u003c/p\u003e \u003cp\u003eThis study has several strengths, including the integration of validated dental quality measures, triangulation of four data sources, and the use of human-centered design and systems frameworks to interpret findings. However, there are limitations. Manual chart reviews, while structured, are subject to abstraction bias. Institutional customization of EHR systems may affect generalizability. The cross-sectional nature of interviews and observations may not fully capture dynamic or seasonal shifts in workflow. The presence of observers may have altered clinician behavior, although this potential Hawthorne effect was mitigated through corroboration with EHR and interview data (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFuture research should focus on prospective trials evaluating the impact of integrated decision-support tools and team-based care models on preventive quality measure performance. Economic evaluations are needed to quantify cost savings associated with reduced restorative burden from improved prevention. In parallel, co-design efforts with patients and families could inform the development of communication tools that are contextually relevant and health-literate.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis mixed-methods study advances dental quality measure research by providing a comprehensive, multi-level view of the operational and contextual drivers behind persistent quality gaps in caries prevention and management across distinct dental institutions. Through the innovative application of the Double Diamond framework and triangulated methods integrating chart reviews, interviews, and clinical observations, we identified systems-level barriers that contribute to inconsistent delivery of evidence-based preventive care.\u003c/p\u003e \u003cp\u003eFindings underscore the need for coordinated interdisciplinary efforts to address these gaps. Stakeholders, including dental professionals, practice leaders, policymakers, and health informatics experts, must collaborate to implement targeted solutions. Leveraging real-time data, standardized quality measures, and embedded clinical decision tools offers a promising path toward improving the consistency and effectiveness of preventive services.\u003c/p\u003e \u003cp\u003eThis study demonstrates the value of integrating multiple data sources and user-centered approaches to inform quality improvement efforts. Such approaches can bridge the gap between evidence and routine practice, enhancing the delivery of patient-centered, preventive oral health care in real-world settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of UTHealth Houston (approval number: HSC-DB-21-0471), and corresponding approvals were secured from all participating institutions. All participants, including patients, caregivers, providers, and staff who were observed or interviewed, provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to institutional and ethical restrictions related to patient and participant privacy. The data include protected health information derived from electronic health records and interview transcripts containing potentially identifiable details. De-identified and aggregated data that support the findings of this study may be made available from the corresponding author on reasonable request and with permission from the participating institutions’ Institutional Review Boards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e“The Authors declare that there is no conflict of interest.’\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported in part by an award\u003c/p\u003e\n\u003cp\u003e5R01DE024166-10 from the National Institute of Dental and Craniofacial Research, National Institutes of Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuhasini Bangar\u003c/strong\u003e: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review \u0026amp; editing, Project administration.\u003cbr\u003e\u003cstrong\u003eJanelle Urata\u003c/strong\u003e: Methodology, Data curation, Investigation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eOluwabunmi Tokede\u003c/strong\u003e: Methodology, Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eSayali Tungare\u003c/strong\u003e: Data analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eHeather Weidner\u003c/strong\u003e: Data analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eAaron Truong\u003c/strong\u003e: Data analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eUrvi Mehta\u003c/strong\u003e: Data analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eAlfa-Ibrahim Yansane\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eGregory W. Olson\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eEmily W. Sedlock\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eDonald Worley\u003c/strong\u003e: Data acquisition, Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eJoanna Mullins\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eRyan Brandon\u003c/strong\u003e: Data acquisition, Data analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eD. Brad Rindal\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eTodd Johnson\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eKrishna Kumar Kookal\u003c/strong\u003e: Data acquisition, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eNicholas Skourtes\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eSwaroop Gantela\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eHeiko Spallek\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eJoel White\u003c/strong\u003e: Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eElsbeth Kalenderian\u003c/strong\u003e: Formal analysis, Data interpretation, Writing – review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eMuhammad Walji\u003c/strong\u003e: Conceptualization, Methodology, Data analysis, Writing – review \u0026amp; editing, Supervision.\u003cbr\u003e\u003cstrong\u003eAna Neumann\u003c/strong\u003e: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review \u0026amp; editing, Supervision.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported in part by an award\u003c/p\u003e\n\u003cp\u003e5R01DE024166-10 from the National Institute of Dental and Craniofacial Research, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBashir NZ. Update on the prevalence of untreated caries in the US adult population, 2017\u0026ndash;2020. J Am Dent Assoc. 2022;153(4):300\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFontana M, Gonzalez-Cabezas C, Tenuta LMA. Evidence-based approaches and considerations for nonrestorative treatments within modern caries management: Integrating science into practice. J Am Dent Assoc. 2024;155(12):1000\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeatherstone JDB, Crystal YO, Alston P, Chaffee BW, Domejean S, Rechmann P, et al. Evidence-Based Caries Management for All Ages-Practical Guidelines. Front Oral Health. 2021;2:657518.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaadoudi F, Trescher A, Duijster D, Maskrey N, Gabel F, van der Heijden GJ, et al. A Consensus-Based Set of Measures for Oral Health Care. J Dent Res. 2017;96(8):881\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar SV, Yansane A, Neumann A, Johnson TR, Olson GW, Bangar S, et al. Measuring sealant placement in children at the dental practice level. J Am Dent Assoc. 2020;151(10):745\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangar S, Neumann A, White JM, Yansane A, Johnson TR, Olson GW, et al. Caries Risk Documentation And Prevention: eMeasures For Dental Electronic Health Records. Appl Clin Inf. 2022;13(1):80\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrandon RG, Bangar S, Yansane A, Neumann A, Mullins JM, Kalenderian E, et al. Development of quality measures to assess tooth decay outcomes from electronic health record data. J Public Health Dent. 2023;83(1):33\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesign Council. A Study of the Design Process\u0026mdash;The Double Diamond. 2005 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.designcouncil.org.uk/our-resources/the-double-diamond/\u003c/span\u003e\u003cspan address=\"https://www.designcouncil.org.uk/our-resources/the-double-diamond/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen Y, Bosch G, Pino L, Gopalan V. Use of the 'double diamond' design framework to nurture creativity in life sciences research. Trends Biochem Sci. 2024;49(8):654\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Branham R, Hsiao W, Chen S, Huang Y, editors. 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CDT 2024: Current Dental Terminology Book 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePsek WA, Stametz RA, Bailey-Davis LD, Davis D, Darer J, Faucett WA, et al. Operationalizing the learning health care system in an integrated delivery system. EGEMS (Wash DC). 2015;3(1):1122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBooth ET, Eckert GJ, Fontana M. Variability in caries management decision-making in a dental school setting. J Dent Educ. 2022;86(1):57\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH, et al. Dentists' use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol. 2011;39(6):564\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark M, Patel F, Santos MJ, Tikhonova S, Athanasakos A, Jessani A. Utilization of caries risk assessment tools within the underserved population: a scoping review. BMC Oral Health. 2025;25(1):330.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol. 2014;67(3):267\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"caries detection/diagnosis/prevention, electronic dental records, caries, dental informatics/bioinformatics, dental public health","lastPublishedDoi":"10.21203/rs.3.rs-7963779/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7963779/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Despite established evidence-based guidelines, the prevention and management of dental caries varies across clinical settings. This study aimed to identify and understand quality gaps in caries prevention and management across four dental institutions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods study was conducted across four large dental institutions. Three data sources were integrated: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) structured chart reviews (n\u0026thinsp;=\u0026thinsp;2,000) using six validated dental quality measures; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) semi-structured interviews (n\u0026thinsp;=\u0026thinsp;102) with patients, caregivers, staff, and dental providers; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) ethnographic observations of clinical care (n\u0026thinsp;=\u0026thinsp;64) using the AEIOU framework. Data were triangulated using thematic coding and root cause analysis. Quality gaps were categorized as quantitative and qualitative gaps, and system-level challenges.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree categories of gaps emerged. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Quantitative gaps included low sealant placement (33.7%\u0026ndash;54.6% in ages 6\u0026ndash;9; 17.5%\u0026ndash;43.0% in ages 10\u0026ndash;14), inconsistent caries risk documentation (50.4%\u0026ndash;99.6%), and high rates of untreated (23.1%\u0026ndash;56.4%) and no new decay rates (65.9%\u0026ndash;80.6%). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Qualitative gaps included limited documentation of preventive therapies, oral hygiene instruction, and nutritional counseling. Providers cited time constraints, unclear CRA protocols, and EHR usability issues. Interviews revealed unclear team roles and limited patient awareness of preventive options. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) System-level challenges included workflow inefficiencies, fragmented responsibilities, and poor integration of CRA and preventive codes into clinical routines. Observations confirmed misalignments between documented and delivered care and missed opportunities for risk communication and same-day preventive interventions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSubstantial quality gaps persist in caries prevention and management despite institutional protocols. These gaps result from a complex interplay of systems, providers, and patient-level factors. Findings emphasize the need for coordinated data-informed strategies to improve the consistency and effectiveness of preventive care. This study highlights the value of integrating multiple data sources and user-centered methods to inform quality improvement in dental settings.\u003c/p\u003e","manuscriptTitle":"Identifying Gaps in Caries Prevention and Management: A Multi-Institutional Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:07:28","doi":"10.21203/rs.3.rs-7963779/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-26T04:57:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276092204834700147199185014246492741396","date":"2025-12-24T13:06:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T09:09:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-14T13:53:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-13T12:20:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-13T12:19:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-27T20:55:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55de4c20-1105-4e47-988e-513df223010b","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T09:07:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:07:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7963779","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7963779","identity":"rs-7963779","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}