Evaluating Trust in the Patient–Dentist Relationship: A Mixed-Method Study

Abstract

Background:

The objective of this article was to understand the trust of study participants in dental providers and trust-building practices used by dentists to establish and maintain trust with their patients.

Methods:

This study used a concurrent cross-sectional mixed-methods design to measure the participants’ trust in their dental providers. An 11-item Dental Trust Scale (DTS) questionnaire was administered to 150 White, Black, and Hispanic study participants. In addition, the research team conducted semistructured interviews with 7 dentists in order to understand their perspectives related to patient trust. The internal consistency of the DTS was tested using Cronbach’s α. Univariate and multivariable logistic regression models were run to test the association between the DTS mean score and individual participant factors. Qualitative information from interviews was analyzed using a thematic analysis approach.

Results:

The overall mean score of dental trust for the entire sample was 3.4. The DTS had good internal consistency (α = 0.93). Overall, dental trust was significantly higher in participants who had a regular dentist (F = 8.74, P = 0.003). The qualitative data were grouped under these key thematic categories: the importance of trust, building trust, and trust in treatment planning. Qualitative analysis also showed that the 2 main trust-building tools used by dentists were communication and understanding the patient’s lifestyle or social determinants of health.

Knowledge Transfer Statement:

This study provides insight into the dentist–patient relationship. It increases our understanding of levels of dental trust among patients and examines methods used by the dentist to build trust. The outcomes of this study can be considered by dentists in their everyday practice as they seek to build trust with their patients.

Keywords

dental home regular dentist trust-building methodologies dentist–patient connection private dental office mixed-method research

Introduction

Trust between a health care provider and patient is the foundation of favorable health outcomes and an integral part of the “social contract” between providers and patients (Rogers 2002; Yamalik 2005). Trust between health care professionals and their patients has long been associated with beneficial health behaviors, fewer symptoms, better quality-of-life outcomes, and greater patient satisfaction (Birkhauer et al. 2017).

Literature notes that the dental profession’s relationship with society relies on, among other things, trustworthiness (Holden et al. 2022) and that a dentist’s work satisfaction correlates positively with their community’s trust in them (Berthelsen et al. 2011). Provider competence, compassion, reliability, and dependability affect patient trust (Lahti et al. 1996; Thom and Campbell 1997; Yamalik 2005). Since trust between a dental provider and their patient significantly affects patient utilization of care, patient satisfaction, and patient compliance with professional advice, it is essential for providers to understand best how to develop and maintain trust with patients (Graham et al. 2004; Murphy 2012; Edwards et al. 2013; Armfield and Ketting 2015; Armfield et al. 2017).

Differences in the level of trust in health care providers exist across different ethnic minority patient groups (Adegbembo et al. 2006; Schwei et al. 2014). Cultural differences, low socioeconomic status, and historical mistreatment have also indicated decreased trust and overall oral health (Armstrong et al. 2007; Butani et al. 2008). Additional barriers for immigrant populations, such as Hispanic patients, may amplify levels of mistrust between patients and dentists. Other obstacles for immigrant populations include difficulty understanding the insurance system, the inability of dental providers to speak the patient’s preferred language, and cultural differences between the patient and provider (Maupome, McConnell, and Perry 2016; Maupome, McConnell, Perry, Marino, et al. 2016). Limited evidence suggests that lower patient trust levels lead to an increased likelihood of dental visit avoidance and more significant risks for poor oral health outcomes (Armfield and Ketting 2015).

The objective of this article was to determine the level of trust patients have in dental providers and explore trust-building practices used by dentists to establish and maintain trust with their patients. The study explored the perspective from both the patient and the dentist’s side using a mixed-methods approach.

Methods

The study was approved by the Colorado Multiple Institutional Review Board (Protocol 19-2375). Using a cross-sectional mixed-methods approach, this study used a quantitative methodology to query the level of trust of the patient in their dentist. It explored how the patients’ racial and socioeconomic variations affected that trust. In addition, a qualitative methodology was used to understand the importance of trust and techniques to build trust by the dentist. The study was a partially mixed concurrent equal-status design, meaning that the data were collected simultaneously, and the results were not mixed until both the data types were collected and analyzed (Leech and Onwuegbuzie 2009).

Quantitative Study Design and Data Collection

Questionnaire methodology was used to measure patient trust in their dental providers. An 11-item Dental Trust Scale (DTS) survey measuring trust level in the dental profession was used. The DTS was developed by a team of researchers from the United Kingdom and Australia (Armfield et al. 2017). The DTS scale has been tested for reliability and validity within the Australian population (Armfield et al. 2017). Cronbach’s α was used to estimate the reliability of the DTS based on internal consistency. The DTS had good internal consistency and high reliability.

For this study, in addition to the 11-item DTS scale, additional questions were included: age, gender, race/ethnicity, annual household income, type of dental insurance, and highest educational attainment. In addition, participants’ regular dental visits and their self-reported oral and general health ratings were recorded.

Participants 18 years and older were recruited from the Denver Metro Area to complete the survey. A total of 150 participants were recruited from community centers, health fairs, and local community events. Participants were self-reported as White, African American, or Hispanic. Participant eligibility criteria included that the participant had seen a dentist in the past 12-mo period. Eligible participants were asked to provide written consent to participate in the research study and complete the DTS survey questionnaire.

In-person data collection was conducted between November 2019 and February 2020. This included collecting data from patients at health, community, and cultural events hosted by our partner organizations. All in-person data collection was suspended in March 2020 due to the COVID-19 pandemic. Data collection was recommenced online in April 2020. The research team conducted video calls with community organizations to reorient them to an online version of the study and requested support in recruiting participants. Participants were recruited via phone or email and subsequently completed the survey online. The survey was available in English or Spanish and was completed on REDCap software (Research Electronic Data Capture, hosted at the University of Colorado). REDCap is a secure, web-based software supporting clinical research data capture, which includes 1) an interface for validated data capture, 2) audit trails for tracking data manipulation and export, and 3) automated export for download to common statistical packages. During in-person data collection, the survey was loaded onto an iPad and made available to participants. Electronic data capture tools were hosted at the University of Colorado Anschutz Campus. When the study was moved to the online format, a REDCap link was sent to participants. Participants were then able to complete the questionnaire on their laptop, iPad, tablet, or mobile phone.

Qualitative Study Design and Data Collection

The qualitative study followed a thematic approach, which is classified under the qualitative descriptive design (Vaismoradi et al. 2016). The goal of using this design is to focus on the content presented by the participant, with subjective meaning and social realities conveyed in this research report.

An iterative process was used by the research team to develop focus areas and subsequently generate corresponding questions for the semistructured interviews (Wright et al. 2004; Dang et al. 2017). The research team conducted meetings to discuss the focus areas of the interviews, directed at understanding the dentist’s perspective related to trust between the patient and the dentist. Thus, the following focus areas were developed:

a. Importance of trust

b. Building of trust

c. Trust in treatment planning

Based on these focus areas, the research team developed the following questions for the semistructured interviews.

How important is trust between you and the patient for successful treatment outcomes?

Do you feel your patients have trust in you?

How important it is to you that your patients trust you?

How do you build trust with your patients?

How do you decide on a treatment plan for your patients?

Several probes were used by the interviewer to elicit more in-depth information on particular themes that included asking the dentist to elaborate on the answer they provided, give examples of situations and techniques they use to build trust, and ask to provide in-depth perspectives on the importance of trust to them. One example for the probe would be: Can you give an example of a situation where you are able to build trust with a new patient?

Qualitative semistructured interviews were conducted with dentists to understand how they established trust with their patients. Snowball sampling was used to recruit dentists in this study (Johnson 2014). This method relies on referrals from an initial sample of dentists who had agreed to participate in the study. The research team had approached a pediatric dentist and a dentist who work at a Federally Qualified Health Center (FQHC) who agreed to participate in the study. These 2 dentist participants provided several referrals, who were contacted, and those dentists who agreed to participate in the study were then interviewed. The interviewer did not personally know the participating dentists. A total of 10 dentists were approached, of whom 7 agreed to participate. These dentists had been in practice for a range of 7 to 15 y, and 4 were women and 3 were men. All 7 interviews were conducted using a video platform by 1 person (TT) to improve the research method’s reliability and rigor. The interviews lasted between 35 and 50 min with each dentist.

Data Analysis

Quantitative data analysis

DTS responses were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher trust. Mean scores and standard deviation were used to summarize the 11 items of the DTS (Table 1). The DTS’s internal consistency was tested using Cronbach’s α, and the item intercorrelations were reported using Pearson r correlation coefficients (Table 2). Descriptive statistics of the categorical demographic and socioeconomic status variables were summarized using frequency and percentage (Table 3).

Table 1.

Descriptive Statistics of the 11 Items from the Dental Trust Scale.

Item	Mean^a	SD
Dentists care about my health just as much or more as I do.	3.9	0.9
Sometimes dentists care more about what is best for them than about my dental needs.^b	2.9	1.2
Dentists are extremely thorough and careful.	3.8	1.0
I completely trust dentists’ decisions about which dental treatments are best.	3.6	1.1
Dentists are totally honest in telling me about all the different treatment options available for my conditions.	3.4	1.1
Dentists think only about what is best for me.	3.3	1.1
Sometimes dentists do not pay full attention to what I am trying to tell them.^b	3.4	1.0
Dentists always use their very best skill and effort on my behalf.	3.8	1.0
I have no worries about putting your oral health in the hands of the dentist.	3.7	1.1
A dentist would never mislead me about anything.	3.1	1.1
All in all, I trust dentists completely.	3.4	1.1

Mean: range = 1–5.

Reverse-coded items.

Table 2.

Pearson Correlations between Dental Trust Scale (DTS) Items.

Item	DTS-2^a	DTS-3	DTS-4	DTS-5	DTS-6	DTS-7^a	DTS-8	DTS-9	DTS-10	DTS-11
DTS-1	0.24	0.62	0.59	0.56	0.44	0.30	0.65	0.56	0.47	0.56
DTS-2^a	—	0.30	0.45	0.38	0.28	0.38	0.39	0.38	0.32	0.45
DTS-3		—	0.74	0.64	0.56	0.38	0.70	0.64	0.54	0.70
DTS-4			—	0.76	0.66	0.43	0.77	0.71	0.58	0.79
DTS-5				—	0.65	0.46	0.75	0.61	0.62	0.73
DTS-6					—	0.29	0.62	0.48	0.53	0.68
DTS-7^a						—	0.47	0.47	0.38	0.45
DTS-8							—	0.70	0.56	0.75
DTS-9								—	0.56	0.71
DTS-10									—	0.75

All correlations are significant at P < 0.01.

Reverse-coded items.

Table 3.

Descriptive Statistics of Demographic and Socioeconomic Status Variables (N = 150).

Variable	Frequency (%)
Age, y
18–28	39 (27.46)
29–38	37 (26.06)
39–48	24 (16.90)
49–58	27 (19.01)
≥59	15 (10.56)
Gender
Male	44 (29.33)
Female	104 (69.33)
Other	2 (1.33)
Race/ethnicity
White	66 (44.0)
African American	28 (18.67)
Hispanic	48 (32.0)
Other	8 (5.33)
Education
Less than high school	1 (0.67)
High school or equivalent	7 (4.67)
Greater than high school or equivalent	8 (5.33)
Some college and college degree or higher	134 (89.33)
Annual household income
$10,000	8 (5.37)
$10,000–$20,000	11 (7.38)
$20,000–$40,000	13 (8.72)
$40,000–$75,000	51 (34.23)
>$75,000	66 (44.30)
Dental insurance
Commercial	84 (66.0)
Medicaid	15 (10.0)
Medicare with HMO benefits	6 (4.0)
Other	29 (19.33)
Oral health rating
Excellent	28 (18.92)
Very good	58 (39.19)
Good	42 (28.38)
Fair	15 (10.14)
Poor	5 (3.38)
General health rating
Excellent	33 (22.15)
Very good	66 (44.30)
Good	41 (27.52)
Fair	8 (5.37)
Poor	1 (0.67)
Regular dentist
Yes	127 (85.23)
No	22 (14.77)

HMO, health maintenance organization.

Associations between DTS mean scores and individual participant factors, including the type of dental insurance, having a regular dentist, and rating oral and general health by race/ethnicity, were tested using analysis of variance (ANOVA) and F tests (Table 4). These associations were also tested in a sample of data obtained during the COVID-19 pandemic from April 2020 onward. Mean, F, and P values were reported.

Table 4.

Differences in Dental Trust Scale Mean Scores by Individual Factors.

	Entire Sample (N = 150)		White (n = 66)		African American (n = 28)		Hispanic (n = 48)		During COVID-19 (n = 58)
Variable	Mean	F	Mean	F	Mean	F	Mean	F	Mean	F
Have a regular dentist
Yes	3.6*	8.74	3.5	0.14	3.4	0.20	3.7	9.89	3.6	3.26
No	3.0		3.4		3.3		3.0		2.9
Type of dental insurance
Commercial	3.5	0.96	3.6	1.24	3.5	0.96	3.4	0.90	3.5	1.48
Medicaid	3.6		3.6		3.2		3.8		3.8
Medicare with HMO benefits	3.3		4.3		2.2		3.3		5.0
Other	3.6		3.2		3.7		3.6		3.7
Rate your oral health
Excellent	3.5	1.03	3.6	0.14	3.5	0.38	3.2	1.96	3.5	0.18
Very good	3.5		3.5		3.6		3.7		3.5
Good	3.5		3.5		3.3		3.7		3.7
Fair	3.2		3.7		3.2		3.2		3.3
Poor	3.1		3.5		3.7		2.7
Rate your general health
Excellent	3.5	0.07	3.6	1.19	3.6	1.57	2.3	2.34	3.4*	3.76
Very good	3.5		3.4		3.6		3.5		3.3
Good	3.5		3.7		2.9		3.5		4.2
Fair	3.5						3.4
Poor	3.7				3.7

Analysis of variance and F tests were conducted to obtain individual factors’ F and P values. Dental Trust Scale mean score treated as continuous outcome variable. Empty cells indicate no response by the study participants.

HMO, health maintenance organization.

P < 0.01.

Univariate logistic regression models were run to test the association between the DTS mean score (scaled mean, low/high: <3.4/≥3.4) and individual participant factors. A multivariable ordered logistic regression analysis model was run to determine the association between DTS mean score (scaled mean, low/high: <3.4/≥3.4) and all the participant factors (Table 5). Odds ratio estimates, 95% confidence interval (CI), and P values were reported. The model was estimated using the likelihood ratio method. A significance level of <0.05 was used to test all the hypotheses. All the data cleaning and analyses were conducted using SAS (version 9.4; SAS Institute).

Table 5.

Participant Factors Associated with Dental Trust Scale Mean Scores.

Variable	Odds Ratio^a	95% CI	P Value^a
Age, y			0.151
18–28	1.10	0.24, 5.01
29–38	2.08	0.48, 9.03
39–48	2.42	0.49, 11.97
49–58	0.47	0.09, 2.53
≥59 (reference)
Gender (female vs. male)	1.19	0.44, 3.22	0.943
Race/ethnicity			0.660
White (reference)
African American	0.95	0.29, 3.07
Hispanic	0.66	0.21, 2.07
Other	2.15	0.30, 15.29
Education			0.195
Less than college degree (reference)
Some college and college degree or higher	3.29	0.54, 20.03
Income			0.930
$10,000–$40,000	0.74	0.15, 3.61
$40,000–$75,000	0.92	0.34, 2.47
>$75,000 (reference)
Insurance			0.472
Commercial (reference)	1.15	0.18, 7.4
Medicaid	1.61	0.18, 14.05
Medicare with HMO benefits	1.09	0.35, 3.4
Other
Regular dentist (yes vs. no)	2.07	1.71, 38.26	0.008
Oral health rating			0.754
Excellent	1.21	0.36, 4.02
Very good (reference)
Good	0.74	0.24, 2.27
Fair	2.37	0.41, 13.67
Poor	0.88	0.05, 16.89
General health rating			0.998
Excellent	1.04	0.33, 3.25
Very good (reference)
Good	0.95	0.32, 2.79
Fair	1.31	0.16, 10.69
Poor

Dental Trust Scale mean score treated as categorical outcome variable = low mean score: <3.4; high mean score: ≥3.4 (reference = low).

CI, confidence interval; HMO, health maintenance organization.

Multivariable logistic regression analysis was conducted to estimate odds ratios and P values.

Qualitative Analysis

All interviews were conducted and recorded by 1 member (TT) of the research team, which was then transcribed verbatim by a third party. Prior to the interviews, the interviewees were informed that a third-party transcription would happen and confidentiality would be maintained by not revealing names and compiling the results of all the interviews as a whole and not individually.

Qualitative analysis was completed by 2 team members (TT, NR); they first completed the individual analysis and developed codes before a team approach developed themes and finalized the codes. Coding discrepancies were resolved by an intercoder agreement, where both the researchers discussed the differences and negotiated toward consensus. This study used thematic analysis, which allows the use of deductive approaches and also inductive approaches to raise the perspectives of the participating dentists to a level of conceptualizations of emerging themes (Alhojailan 2012; Campbell et al. 2013). The ideas that emerged in the interviews provided a path to the development of themes outside of the predetermined focus area. Some of the emergent themes were specific to the practice setting, various circumstances, and different populations, and thus the research team decided to place them outside of the predetermined focus areas. Saturation of the data was achieved within the 7 interviews with repetition in the ideas and perspectives seen as the 2 coders completed the analysis.

All qualitative analysis was completed in ATLAS.ti (Scientific Software Development GmbH).

Mixed-Methods Analysis

The mixing of the 2 results was done after the completion of the quantitative and qualitative analysis. This study used the survey methods with 1 set of study participants (patients) and data from the semistructured interviews with another set of participants (dentist). The research team used directed acyclic graph (DAGs) (http://www.dagitty.net/) that helped in the visualization of the variables and concepts from the results that were related to dental trust for both the participant and the provider groups. The data were converged to understand the meaning and development of dental trust for 2 different groups (participants and dentists). The research team used this visualization technique to draw parallels between the trust variables important to both the patient and dentist group (Fig.).

Figure.

Visualization of quantitative and qualitative data. DTS, Dental Trust Scale.

Results

Quantitative Results

A total of 150 participants completed the DTS questionnaire. The means and standard deviations of the 11 items of the DTS are described in Table 1. The overall mean for the DTS for the entire sample was 3.4. The item-level means ranged from 2.9 to 3.9, reflecting the finding that most participants responded to the DTS items with a score of 3 or higher. The standard deviation of the means was relatively consistent across the 11 items, indicating similar distributions. The DTS had good internal consistency (α = 0.93), and corrected item-test correlations ranged from 0.45 (DTS-2) to 0.87 (DTS-11). Correlation coefficients ranged from 0.24 to 0.79 and were lowest overall for the 2 reverse coded items (DTS-2 and DTS-7) (Table 2).

The mean age of the study participants was 28 years, and 52% were under the age of 38 years (Table 3). Sixty-nine percent of participants were female, and of the 150 participants, 44% were White, 19% were African American, and 33% were Hispanic. Eighty-nine percent of participants had completed some years of college or had a college degree, and 44% had an annual household income >$75,000. The majority of the study participants rated their general health to be excellent/very good/good. Eighty-five percent of the participants reported having a regular dentist.

Table 4 provides the stratified results for the entire sample, race/ethnicity groups, and the sample data collected during the COVID-19 pandemic. Participants who had a regular dentist reported significantly higher dental trust (F = 8.74, P = 0.003). Hispanic participants who reported having a regular dentist reported significantly higher dental trust than those without a regular dentist (F = 9.89, P = 0.003), a finding not observed among White and African American participants. For the sample data collected during the COVID-19 pandemic, dental trust was significantly higher in participants who reported having excellent general health (F = 3.76, P = 0.019).

Having a regular dentist was significantly associated with higher dental trust in univariate analysis. Participants who reported having a regular dentist reported 4 times higher odds of trusting dental care providers (odds ratio [OR], 4.1; P = 0.005) than participants who did not report having a regular dentist.

In the multivariate ordered logistic regression analysis (Table 5), participants who reported having a regular dentist had 2 times higher odds of having trust in dental providers (OR, 2.07; P = 0.008) than the participants without a regular dentist.

Qualitative Results

In analyzing the semistructured interviews with the dentists, some themes applied to all the participating dentists; however, some were specific to the type of practice or patient groups the dentists served. Three main focus areas, the importance of trust, the building of trust, and trust in treatment planning, were the deductive components of the research. We saw a few more themes emerge that were related to trust building in specific situations, including understanding different beliefs and cultures, trust building in rural areas, and dental trust in the age of a pandemic—these were inductive components of qualitative research.

Importance of trust

All the dentists discussed the importance of trust in providing care to their patients. Some of them mentioned it as the “cornerstone of their dental practice.” They discussed that they invested time in building trust with patients because it was a central component of delivering good oral health care to their patients and establishing a dental home for the patient.

Almost all the dentists discussed a trust-building technique—which they characterized as the “best interest of the patient.” Dentists emphasized that they invested time in understanding what outcomes the patient wanted and how they could promote patient autonomy and meet their patient’s expectations without compromising the treatment. Listening to the patient helped them understand the perspective of the patient. Dentists said that they build trust with patients during the treatment planning, where they provided all possible treatment options to the patient and then discuss each possibility in detail. The dentists believed that was one of the significant predictors of trust building with their patients.

I always circle back to what the patient wishes to do versus what treatment I am proposing and then try to meet them in the middle.

Dentists who owned dental practices further commented on the “best interest of the patient” concept. They suggested that it was essential to separate the business model for their dental office and treatment planning for their patients. They said doing so enhances the patient’s confidence in the dentist and increases the likelihood that they will consider them as their regular dental office or dental home.

I have to look for the best interest of my patient and advise them accordingly because the best thing for them may not be the best thing for me.

Building of trust

Also, they discussed how they intentionally do not consider their patient’s insurance or ability to pay when providing them treatment options. They further described this as “universal treatment planning.” Dentists said it was imperative to treat all patients the same when treatment planning regardless of their financial situation, noting that it helps reduce bias and helps the dentist develop a pattern of communication and practice. These methods support the building of trust with their patients and their own and their office’s reputation in their community.

I treat every patient the same in that respect, and I give them all the same treatment planning options.

Trust in treatment planning

Dentists’ 2 main trust-building tools were communication and understanding the patient’s lifestyle or social determinants of health. Communication was considered the critical trust-building tool by all the dentists. They said it was vital to listen to the patient’s concerns, make eye contact with the patient, and give the patient their undivided attention while the patient describes their reason for the visit. It was emphasized that providing a step-by-step discussion from the diagnosis, treatment planning, and long-term outcomes helped build trust with patients. Communication also included the understanding that patients may not adhere to all recommendations provided to prevent further disease.

I am a pediatric dentist and work with kids and parents. I understand that it is hard for parents to floss their child’s teeth at night. Therefore, I have developed a nonjudgmental and nonshaming approach. I let them know that I, too, have kids, and I understand the difficulties of parenting.

Another essential tool dentists discussed was understanding the “life history of the patient,” which is often to referred to as “social determinants of the patient’s health.” Most of the participating dentists said that they take in-depth social histories from patients. This provides them an opportunity to deliver treatments that best suit their patients’ lifestyles.

I work a lot with older adults; if they are being brought to the clinic by a caregiver, I may do longer appointments, so they don’t have to come several times.

Some of my patients may not have a car. I will make a note of it and tell my front desk to schedule a longer appointment for them so that we can accomplish more treatment in one sitting.

I see a lot of patients who come to the clinic when they are in pain. I work with them to remove the disease before we move on to other things.

Trust building in specific situations

Dentists who worked in FQHCs described additional trust-building techniques. They emphasized the need to understand the patients’ beliefs and cultures, which they believed played an essential role in discussions about treatment planning. Dentists said that they struggled to understand the outcomes that the patients wanted, as it was harder to communicate with some of their patients due to language barriers or differences in communication styles. It was reported that patients occasionally fail to express their thoughts because the patient believes the dentist is the ultimate authority in deciding the treatment.

I will try and speak to the patient as much as I can to understand what they want from the treatment. It is tough to do it in the short time we have with the patients. However, I struggle the most when the patients say, “We will do whatever you suggest, doctor.” I can recommend the treatment options, but I cannot make the decisions for them.

A few dentists who practiced in rural areas mentioned that rural communities are smaller and more connected and that patients would discuss the dental provider’s trustworthiness in social settings. The dentists noted that they met their patients commonly outside their practice as it is a small town and therefore they must build trust with the entire community. In some cases, they were the only provider in the town with no specialist for referrals and would have to refer patients to specialists in another town or urban area. Thus, it was imperative that their patients have high trust in them and the treatment planning to go to a specialist in another town.

I practice in a small rural town, and if I was not trustworthy or if I was sketchy, I would have heard from people around town.

Dental trust in the age of a pandemic

Dentist interviews were conducted in May to June 2020 when dental offices in Colorado were permitted to reopen after lockdown due to the COVID-19 pandemic. Therefore, some interview discussions steered in the direction of “dental trust in the age of a pandemic.” Dentists who owned practices and the pediatric dentist discussed that most of their patients exemplified their trust in them by returning for dental treatment and preventive visits after the COVID-19 lockdown. The pediatric dentist discussed parents’ dedication to their children’s oral health care and noted that she was not surprised by parents’ treatment demands. She discussed how her patients’ parents trusted her with their child’s dental treatment and that the clinic provided them with the most up-to-date infection control. The dentists also described that there would be pent-up demand for preventive and restorative dental care in their patient population following the COVID-19 lockdown.

So actually, the parents wanted treatment for their children; they wanted the fillings. I can’t say that I’ve noticed much difference at work; no one has asked me anything specific related to infection control that—did you clean that or what are you doing, and why are you doing. And again, I do think that they trust us, I really do.

The conversation with the FQHC dentists was slightly different. Although their office had reopened for routine dental care, these dentists noted that they only saw patients for urgent and emergency care. They also discussed that patients who came in were in pain. Furthermore, the FQHC dentists discussed that the patients who returned for treatment seemed more concerned about infection control and asked questions about it.

So, the patients are now much more alert than they were ever before. And they are asking every time, are you doing this, are you doing that, are you wiping the chairs.

Discussion

This study evaluated the trust of study participants in their dentists using the Dental Trust Scale and evaluated how dentists build trust with their patients. The overall mean of this survey was similar to the original DTS (3.4 vs. 3.6), although the population group included in the original DTS was different from this study. The original study was conducted with an urban Australian population, and our study sample had urban White, Hispanic, and African American populations. Also, DTS demonstrated high reliability and validity in the current study.

The survey results revealed that participants who reported having a regular dentist had higher trust in their dentist. Several studies in the literature reiterate that establishing a dental home can improve oral health outcomes, decrease dental anxiety, and establish trust with the dentist (Graham et al. 2004; Sohn and Ismail 2005; Reda et al. 2018).

Most study participants were younger and college educated who rated their oral health as “good,” “very good,” or “excellent” with incomes higher than $40,000 and commercial dental insurance. Considering that a variety of factors such as income, education, and race/ethnicity contribute to a patient’s trust in their provider (Butani et al. 2008), the demographic composition of the study sample could lend itself to higher DTS scores as compared to other populations.

Although the DTS was initially developed to be analyzed as a single scale, we included select individual items from the DTS along with the mixed-method analysis. DAGs were used to help visualize these parallel results (results of the survey participants and results of the dentists) from 2 different groups to infer conclusions of the dentist–patient relationship (Fig.). One of the themes seen in the qualitative analysis was that most dentists thought of their patient’s best interest in treatment planning. In the DTS, 2 questions (DST-4 and DST-5) captured similar thoughts from patients. Participants reported a mean score of 3.6 and 3.4, respectively, to questions that asked about trust in dentists’ decisions about which dental treatments are best and to the honesty of the dentist in the discussion of different treatment plans. These common parallel responses provide grounds for the interpretation of dentists’ trust-building methodology and patient receptiveness.

In addition, in the semistructured interviews and the DTS, communication between the patient and dentist rose to be the primary tool for building trust. In the DTS, participants indicated that their dentist paid full attention to their concerns (mean = 3.4), while in semistructured interviews, dentists conferred the same. In recent years, the concept of the patient-centered dental home has been integrated into dentistry. Within this concept, improved communication with patients has been noted to be one of its core foundations (Damiano et al. 2019). Dentists’ communication skills are considered an essential tool in the development of positive patient attitudes and their overall satisfaction with the care provided (Yamalik 2005). Furthermore, in both the semistructured interviews with the dentist and DTS, it was seen that trust-building methodologies and patient perceptiveness were successful when the patient had a dental home.

COVID-19 posed unique challenges for dentists to build and sustain relationships with patients. During the qualitative interviews, the dentists shared that they felt their patients trusted them during the pandemic and were comfortable returning for treatment following the COVID-19 lockdown. It is possible that patients with established, trusting relationships with a dentist are more likely to perceive oral health as a priority, which promoted them to return to the dentist once restrictions were lifted.

Like all research, this study has a few limitations. Recruitment for this study was done in person until March 2020, and later, due to COVID-19, it was done online from mid-April 2020. The discrepancy between in-person and virtual recruitment could have affected the representation of the study sample. Although the same community organizations helped to recruit participants for the in-person and virtual survey, more technologically savvy individuals and individuals who had access to a cellphone or computer may have opted to participate in the latter. The recruitment for the qualitative interviews used the snowball method, which is prone to selection bias. The length of the qualitative interviews was between 35 and 50 min, which was based on the time available for the participating dentists. No information on the age and race/ethnicity of the dentists was collected, which may influence trust between patients and dentists. All survey and qualitative research has a component of social desirability. This study included a cross-sectional study design and a small sample of both participants and dentists. The study data were collected in the Denver Metro Area in Colorado and thus cannot be generalized to the US population. However, this study used mixed methods to improve the rigor of the analysis. Furthermore, this is the first research study conducted using the Dental Trust Scale in the United States.

In conclusion, this study provides an initial insight into the partnership of the dentist–patient relationship. It increases our understanding of the current methodologies used by the dentist to build trust and the current levels of trust among patients. Further longitudinal research is warranted in identifying the critical elements for how patients establish trust in order for the dentist to maximize trust-building efforts to produce better oral health outcomes.

Author Contributions

T. Tiwari, contributed to conception, design, data acquisition, drafted and critically revised the manuscript; N. Rai, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; J. Holtzmann, contributed to conception, design, data acquisition and interpretation, critically revised the manuscript; L. Yates, contributed to data acquisition and interpretation, critically revised the manuscript; V. Diep, N.N. Maliq, contributed to data analysis and interpretation, critically revised the manuscript; E.P. Tranby, J. Frantsve-Hawley, contributed to conception, design, data analysis and interpretation, critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Supplemental Material

sj-pdf-1-jct-10.1177_23800844221087592 – Supplemental material for Evaluating Trust in the Patient–Dentist Relationship: A Mixed-Method Study

Supplemental material, sj-pdf-1-jct-10.1177_23800844221087592 for Evaluating Trust in the Patient–Dentist Relationship: A Mixed-Method Study by T. Tiwari, N.N. Maliq, N. Rai, J. Holtzmann, L. Yates, V. Diep, E.P. Tranby and J. Frantsve-Hawley in JDR Clinical & Translational Research

Footnotes

Acknowledgements

We thank all the individuals who completed the survey and the dentists who participated in the interviews.

A supplemental appendix to this article is available online.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. V. Diep, E.P. Tranby, and J. Frantsve-Hawley are employees of Carequest Institute for Oral Health.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The funding for this project was provided by the CareQuest Institute for Oral Health.

ORCID iDs

T. Tiwari

N. Rai

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