Visit-Level Quality Measurement Reveals Missed Opportunities and Overuse in Preventive Oral Health Care

Authors

• Bunmi Tokede, University of Texas Health Science Center
• hasini Bangar, University of Texas Health Science Center
• Swaroop Gantela, University of Texas Health Science Center
• Ryan Brandon, Willamette Dental
• Alfa Yansane, University of California - San Francisco
• Donald B. Rindal, HealthPartners Institute
• Don Worley, Health Partners Institute
• Joel White, University of California - San Francisco
• Joanna Mullins, Willamette Dental
• Ana Neumann, University of Texas Health Science Center
• Todd Johnson, University of Texas Health Science Center
• Nicholas Skourtes, Willamette Dental
• Gregory Olson, University of Texas Health Science Center
• Janelle Urata, University of California - San Francisco
• Heather Weidner, Health Partners Institute
• Katie Lamberger, Willamette Dental
• Aaron Truong, Willamette Dental
• Heiko Spallek, University of Pittsburgh School of Dental Medicine
• Elsbeth Kalenderian, Marquette UniversityFollow
• Muhammad F. Walji, McWilliams School of Biomedical Informatics

Document Type

Article

Publication Date

2-2026

Publisher

American Dental Association

Source Publication

Journal of the American Dental Association

Source ISSN

0002-8177

Abstract

Background

Traditional annual dental quality measures fail to capture real-time care delivery and can mask critical gaps in patient-specific treatment. The authors developed and implemented visit-level adaptations of established caries quality measures to enable actionable, point-of-care assessment.

Methods

The authors conducted a retrospective analysis of 1.09 million dental visits across 400,000 patients (2021-2023) at 4 US institutions using axiUm (Henry Schein Corp) or Epic (Epic Systems) electronic health records. The authors transformed 2 annual measures involving caries risk assessment and risk-based preventive treatment into visit-level metrics using a 2 × 2 matrix framework: action due and performed, due and not performed, not due and performed, not due and not performed. Risk-stratified recall visit intervals determined when actions were due.

Results

Visit-level performance consistently underperformed annual metrics. Annual caries risk assessment completion ranged from 60% through 99% across sites; however, visit-level adherence when actions were due dropped, ranging from 41% through 72%. Results of preventive treatment showed greater disparities; only from 28% through 35% of indicated treatments were delivered when due, and from 7% through 32% of visits included treatment when not indicated. Sites with the highest annual performance paradoxically had the most overtreatment.

Conclusions

Visit-level quality measurement exposes substantial undertreatment and inappropriate overtreatment invisible in annual reporting. This granular approach revealed that high-performing institutions according to traditional metrics may be delivering unnecessary care and missing critical prevention opportunities. These findings provide an empirical case study of how misaligned incentives and flawed metrics could systematically drive misuse of resources. Implementation of real-time, visit-based quality measures in clinical workflows could fundamentally transform electronic health records from documentation tools into active instruments for delivering appropriate, value-based, person-centered care.

Practical Implications

Oral health care systems should consider visit-level quality measurement as a means to provide actionable, real-time feedback that can improve clinical decision making at the point of care and prevent waste associated with volume-based care.

Comments

Published version. The Journal of the American Dental Association, Vol. 157, No. 2 (February 2026): 175-183. DOI. © 2026 American Dental Association. Used with permission.

This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/ 4.0/).

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.

Recommended Citation

Tokede, Bunmi; Bangar, hasini; Gantela, Swaroop; Brandon, Ryan; Yansane, Alfa; Rindal, Donald B.; Worley, Don; White, Joel; Mullins, Joanna; Neumann, Ana; Johnson, Todd; Skourtes, Nicholas; Olson, Gregory; Urata, Janelle; Weidner, Heather; Lamberger, Katie; Truong, Aaron; Spallek, Heiko; Kalenderian, Elsbeth; and Walji, Muhammad F., "Visit-Level Quality Measurement Reveals Missed Opportunities and Overuse in Preventive Oral Health Care" (2026). School of Dentistry Faculty Research and Publications. 599.
https://epublications.marquette.edu/dentistry_fac/599