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

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.