• Financial. Financial concerns exist at every level of the health care system and can undermine any implementation plan. Anticipating and addressing financial issues are important steps that cannot be ignored. Unanticipated costs, such as those associated with staff training (and retraining when staff turn over), must be included in the plan. The impact of cost on patient demand may also need to be explored. For example, informing patients that the optimal treatment (for example, dental sealants) may not be covered by their insurance may result in unanticipated changes in clinical revenue. There may be upsides in clinical revenue as well. If, for example, a clinic chooses to provide dental sealants applied by expanded-function hygienists rather than restorations that require a dentist for the treatment of early carious lesions, staff salary costs per patient may decline.

It is likely that even the most thoughtful review of cost issues will not fully anticipate the financial impact of changes to care delivery processes. Thus, an organization may need to be prepared for this impact until the new process becomes fully integrated into the clinical workflow and the delivery system is adjusted to accommodate the change. Using the sealant scenario above, there may be short-term losses in clinic revenue as a result of current insurance reimbursement restrictions. But in the longer term, a large clinic might change its staff model to align with the changing care delivery requirements. Additionally, a clinic could document the improved patient outcomes over the long term and address this with payers as part of a renegotiation of the reimbursement model.

Dental schools are mandated by the Commission on Dental Accreditation (CODA) to create and implement evidence-based practice into curricula. This requires a significant investment of time, revenue, and multiple other resources in hiring, training, and calibrating faculty.²¹ Public health organizations (such as community and school clinics, federally qualified health care centers, hospital emergency rooms, and private nonprofits) struggle with limited financial resources as well as significant staff turnover. Creating a culture of evidence-based practice can face significant hurdles. “Safety net” clinics, however, provide an excellent laboratory for exploring and designing workable models. Primary care is often offered under one roof, creating opportunity for interprofessional collaboration and information sharing. Prioritizing treatment according to established CPGs for preventive care (for example, CPGs on sealants or fluoride application) is a common practice in these settings, and outcomes can be measured provided there is financial support for the measurement of outcomes. At the private/group practice level, financial barriers to implementing EBD ranked high among dentists surveyed.20

Traditional methods of reimbursement present a major challenge to the private practitioner. Reimbursement as a function of procedure, rather than diagnosis, can be a disincentive to implementing best available evidence into practice. Third-party insurer coverage rules may not align with EBD and standards of care, and plans might be incentivized to disregard them to limit company exposure. An excellent example of coverage rules that may not align with EBD is the use of pit-and-fissure sealants. There is moderate-quality evidence that shows that placing a sealant over a noncavitated lesion will arrest progression of decay.²² However, some insurance companies may not reimburse for this procedure for premolars and/or patients over an arbitrary age limit.²³

Issues with Medicaid reimbursement are beyond the scope of this chapter. However, approximately 40 million children are insured through Medicaid and the Children’s Health Insurance Program,²⁴ and these numbers should not be ignored when analyzing barriers to implementing EBD. Rewarding providers who prioritize evidence-based practice for this population is worth studying.²⁵ Reimbursement issues rank high as a barrier for private practice.

In creating an EBD-friendly environment, the cost of supplies and equipment, return on investment, and training for the entire team must be considered—including the cost of access to evidence. The American Dental Association (ADA) provides access to CPGs and SRs on its EBD webpage,²⁶ and ADA members can access additional scientific research (for example, Cochrane SRs) through the ADA Library and Archives.²⁷ For nonmember practitioners with no university affiliation, however, there may be additional costs to accessing primary and secondary research papers.²⁶

Finally, the reality is that for the average private practitioner, evidence-based practice takes time. For example, it takes more time to explain to a patient that treating an incipient lesion medically rather than surgically is, in certain scenarios, a preferred option. Patients need to give informed consent, be educated on home fluoride application, be given appropriate oral hygiene instruction (OHI), and receive professional monitoring. These efforts might not be reimbursed. At the consumer level, insurance reimbursement can influence treatment decisions more than evidence-based advice. Proposing and implementing an evidence-based treatment plan depends on many factors, such as ethical considerations and the patient’s perceived value of treatment and oral health. Addressing oral health literacy in many consumer segments demands an enormous investment in time, reframing practice philosophy, and appropriate continuing education for one’s dental team. None of this can take place without a partnership among all stakeholders in oral health.

• Clinical awareness. There are approximately 2.5 million scientific papers being published each year.28 In 2014, there were 28,100 peer-reviewed journals in print and online. The incredible growth in literature has advantages and disadvantages. The obvious advantages are that we have much more information on various processes and interventions regarding what works and what doesn’t. However, there is some evidence that the growing pool of literature is leading to scientists citing fewer and fewer publications.²⁹ This may mean that highly relevant but older papers are not being read anymore.

Practicing dentists do not have the time to wade through the thousands of new dental articles that are published each year. However, they could benefit significantly from better understanding current research. Materials, equipment, and processes improve over time. SRs critically analyze multiple research studies on the same topic to provide a broad summary of the current literature to a particular research question. Critical summaries succinctly describe the pertinent findings of an SR. Online databases such as Epistemonikos provide access to such SRs and critical summaries of current research in dentistry.³⁰ Referencing these resources as an EBD practitioner represents an alteration in the way some clinicians have been taught to diagnose and treat patients in the past, when there was not a step to check the latest scientific evidence.

• Evidence-based dentistry skill. EBD is an important skill set that requires training, as detailed in the previous chapters. Fortunately, implementing EBD in large dental practice or school settings does not need to rely on the evidence selection skills of individual providers. Large organizations might instead have in place a committee of well-trained individuals to periodically review the scientific literature and select current best evidence for implementation. The new evidence could then be driven by organizational-level policy and adopted through best practices of implementation, such as staff training and incentives.

• Staff training. Without proper staff training, implementation with high fidelity is impossible for many clinical procedures and innovations. Thus, an appropriate staff (professional and nonprofessional) training plan should be adopted for each clinical procedure and innovation being implemented. This training plan should be fully developed and consider costs (both direct and opportunity costs), retraining frequency, fidelity monitoring, and the management of staff turnover (for example, consideration of new hires who require timely training before engaging in patient care, and changes in clinic leadership). In some settings, such as large group practices, the use of coaches who are highly trained and supportive can be important in increasing compliance and fidelity among the staff.

Monitoring adoption and fidelity should also be an element of the training plan. Compliance monitoring is typically done through audit and feedback, thus giving each provider the information needed to monitor and manage their own performance. Fidelity is assessed in various ways (such as clinical chart review), again as a means of alerting each provider as to how well they are providing the desired care. The training plan should make clear that such oversight is a regular part of the plan for everyone and is not intended to reflect distrust of any individual provider or result in punitive action.

• Information technology issues. An appropriate, well-developed information technology (IT) infrastructure can help support an implementation plan. For example, if dental sealants are to be applied to noncavitated carious lesions, then an electronic health record must be able to capture the diagnosis and treatment plan accordingly. Evidence from implementation research also suggests that monitoring for fidelity and compliance with new clinical processes is generally required until these processes become the “new normal.” This is known as audit and feedback. Thus, IT infrastructure must support periodic report generation that allows for the monitoring of both fidelity and compliance at the provider level.

• Diagnostic codes. Diagnostic codes are defined by the ADA as “a unique, alphanumeric string of characters that represents a disorder or disease concept. Diagnostic coding is the translation of written descriptions of diseases, illnesses, and injuries into standardized codes.”³¹ When used in conjunction with dental claims, codes on dental procedures and nomenclature (CDT codes) allow for an improved assessment of the appropriateness of care provided and can become an important element in a quality management program. These codes are derived from the International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification (ICD-10-CM).³² At present, there is no universal obligation to use an ICD-10-CM code on dental claims, but there is a growing emphasis from payers on their use.

The appropriate use of diagnostic codes within an implementation plan is just now developing in dentistry. It seems clear that they can provide a valuable contribution to the audit and feedback process and allow for measurement of the degree to which the implementation plan is succeeding. They can also provide feedback on the oral health of a patient population, track trends in oral health status, document fidelity to best practices, permit analysis of patient care services, and analyze the cost-effectiveness and quality of care. The Systematized Nomenclature of Dentistry (SNODENT) is a clinical terminology designed for use in dentistry and is compatible with electronic health and dental records.³³ One of its intended purposes is to provide standardized terms for describing dental disease.

• Peer influence. Peer influence can be an important factor requiring careful management for certain implementation plans to succeed. It is understood that dentists often tend to behave in ways they believe are consistent with their peers.³⁴ In so doing, they are reassured about the appropriateness of the care they provide. This desire to conform creates what might be considered a culture of care in a clinic or community, which can substantially influence decisions about how care is delivered. Managing peer influences can be challenging. Best practices in implementation science suggest that compliance reporting or audit and feedback can be of value when it shows a dentist that peer behavior follows the desired evidence-based practices. Such information can help a dentist to feel confident in adopting a new clinical procedure.

Beyond simple compliance reporting, the use of champions or coaches who are respected peers, can play an important role. Coaches can provide prompt assistance to coachees when, for instance, questions arise around appropriate application of a CPG. Champions are respected thought leaders who, by demonstrating their support of an evidence-based approach, can legitimize its use among others.

• Policy issues. Within a clinical setting, senior leadership (for example, clinic directors) plays an important role by setting policy around how care should be delivered and how quality and compliance will be assessed. Central to the success of any implementation plan is support from senior leadership for the plan. Through policy guidance, leadership should make clear the importance of the plan and provide details that describe how the plan will be supported (for example, training, workflow changes, and incentive plans) and how fidelity will be monitored (for example, audit and feedback).

• Organizational barriers and facilitators. Like most organizations, dental clinics are complex systems. They are made up of care providers and patients who are interacting and responding to clinical, financial, social, and other forces that structure their behavior. Systems are inherently stable and tend to continue to perform in a consistent manner until interventions alter that behavior. An implementation plan is designed to be such an intervention. Effective implementation plans must address in detail the system of care delivery and what barriers and facilitators of change exist within the system. Barriers that need to be addressed are context-specific, meaning that what barriers exist and how they can be removed will vary from clinic to clinic and, just as importantly, from innovation to innovation (for example, implementing a CPG). Although it is hard to generalize what a successful approach will look like, general categories of barriers exist within a clinical setting that need to be considered. Examples of such barriers are lack of knowledge, skill, and openness to change among the professional staff; lack of awareness of an innovation; lack of incentives to change; lack of outcome expectancy; and lack of self-efficacy. Examples of external barriers contributing to these issues are patient and CPG factors such as patient preferences and CPG characteristics, respectively. Multiple environmental factors can also play a role, such as lack of time, lack of resources, reimbursement issues, malpractice liability, and organizational constraints.^35,36