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Abstract
Objectives Selecting effective implementation strategies to support guideline-concordant dental care is a complex process. For this research project, an online deliberative forum brought together staff from dental clinics to discuss the strengths and weaknesses of implementation strategies and barriers to implementation of a component of a dental (pit-and-fissure) guideline. The goal was to determine whether deliberative engagement enabled participants’ sharing of promotive and prohibitive voice about implementation strategies to promote guideline-concordant care.
Design Qualitative analysis of online chat transcripts of facilitated deliberations from 31 small group sessions.
Setting Kaiser Permanente Dental (KP Dental) in the USA.
Participants All staff from 16 dental offices.
Results The directed content analysis revealed that participants shared prohibitive and promotive voice when offering critique of the barriers and the implementation strategies suggested by the researchers. The analysis also revealed that the focus of the deliberations often was not on the aspect of the pit-and-fissure guideline intended by the research team for deliberation.
Conclusions The deliberative forum discussions were a productive venue to ask staff in dental clinics to share their perspectives on strategies to promote guideline-concordant care as well as barriers. Participants demonstrated prohibitive voice and engaged critically with the materials the research team had put together. An important limitation of the deliberation was that the discussion often centred around an aspect of the pit-and-fissure guideline that already was implemented well. To ensure a deliberation oriented towards resolving challenging aspects of the pit-and-fissure guideline, greater familiarity with the guideline would have been important, as well as more intimate knowledge of the current discrepancies in guideline-concordant care.
Trial registration number This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 18 December 2020. https://clinicaltrials.gov/ct2/show/NCT04682730.
- protocols & guidelines
- qualitative research
- quality in health care
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study tested deliberative engagement to engage healthcare professionals in deliberating implementation strategies.
A strength of the study is that deliberative engagement has not been previously tested in this context.
A limitation of our study is that it involved deliberative engagement online with no comparison made to other methods of eliciting voice, including face-to-face deliberative protocols.
Introduction
The implementation of evidence-based guidelines into routine medical care is recognised as an important step in closing the evidence-to-practice gap and improving health outcomes.1 2 Supporting the effective implementation of such guidelines to ensure guideline-concordant care, however, is a well-recognised challenge.3–5 Implementation strategies, defined as ‘methods or techniques used to enhance adoption, implementation and sustainability of a clinical program or practice’,6 are an important tool. Selecting appropriate implementation strategies, however, is a complex process, and there is no clear consensus on which methods are most effective.7 Expanding the toolkit of available methods to engage healthcare professionals was a goal of this study.
Deliberative engagement is an approach originating in political science that seeks to increase public participation in decision making by public institutions8 and may offer a novel approach to deliberate the strength and weaknesses of implementation strategies. Deliberative engagement has been shown to empower citizens of different sociodemographic backgrounds to contribute meaningfully to complex policy discussions.9 For this research study, we designed an online deliberative forum for staff working in dental clinics with the goal of enabling participants to share their voices in deliberations related to improving guideline-concordant care.
The concept of voice—‘intentionally expressing relevant ideas, information, and opinions about possible improvements’10—captures the notion of speaking up and sharing one own’s opinion during deliberative discussions to arrive at an informed opinion. Voice is distinguished into promotive and prohibitive voice.11 Promotive voice focuses on expressions of people’s suggestions for improving existing work practices or introducing new procedures, while prohibitive voice describes expressions of their concern about existing or impending practices or behaviours that may harm an organisation.12–14
For this article, we have analysed the transcripts from deliberations from online forums to determine if deliberative engagement supported the sharing of promotive and prohibitive voice about implementation strategies by participants. To our knowledge, there are no previous studies exploring the role of deliberative engagement in debating the strengths and weaknesses of implementation strategies in a healthcare setting. Understanding if online deliberative forums are a useful tool to empower professionals to share their voices is important, as effective tools are needed to engage healthcare professionals in implementation of evidence-based guidelines.
Methods
Research setting
The Kaiser Permanente Dental (KP Dental) programme is part of the Kaiser Permanente Northwest (KPNW) integrated healthcare system and provides comprehensive, prepaid dental care services to over 260 000 dental plan members in Oregon and southwest Washington. KP Dental is a partnership between Permanente Dental Associates (PDA) and the Kaiser Foundation Health Plan of the Northwest. PDA employs over 150 dentists and specialists including 117 general dentists and 9 paediatric dentists providing care in 21 dental clinics. The health plan operates patient care facilities, provides insurance coverage for members and employs allied dental staff, including dental hygienists and expanded function dental assistants working in the same dental clinics.
Clinical guideline targeted in the DISGO study: pit-and-fissure guideline
For this study, the research team conducted online deliberative forums in 16 dental clinics as part of a stepped-wedge, cluster randomised trial to test the effectiveness of deliberative engagement in improving adoption of the pit-and-fissure dental sealant guideline at KP Dental.15 We excluded five dental offices that were oriented to urgent care primarily as a result of the COVID-19 pandemic. The pit-and-fissure dental sealant guideline recommends the placement of preventive and therapeutic sealants on occlusal (biting) tooth surfaces.16 Preventive sealants are foremost placed on permanent molars of children and adolescents.17 Therapeutic sealants are recommended for placement on occlusal surfaces to arrest non-cavitated caries.18 Guideline adherence to the placement of preventive sealants was high at KP Dental; however, adherence to the placement of therapeutic sealants was low across all clinics with the exception of one (see Polk et al Testing a Deliberative Democracy Engagement Intervention to Increase Guideline-Concordance Among Oral Health Providers: Results from the Dissemination and Implementation of Sealant Guidelines in Organizations (DISGO) Cluster-Randomized, Stepped-Wedge Trial, This publication remains under review and no additional details are available yet), and the focus of this study was on improving adherence to this aspect of the guideline. Increasing the placement rates of preventive sealants had been the focus of previous, internal implementation efforts at KP Dental and also was promoted by a goal set by the Oregon Health Plan for organisations receiving reimbursement for Medicaid patients.
Deliberative forum
During deliberative discussions, citizens are brought together to discuss their perspectives on a given topic. At the core of deliberative engagement rests the assumption that people develop a more informed opinion about issues when they have an opportunity to engage with expert information and the diverse perspectives of others in well-structured discussions.9 When provided with the informed opinions resulting from deliberative engagement, public officials are able to take complex considerations into account when crafting policy, resulting in decisions that both reflect public input and enjoy greater legitimacy among them.19
The underlying premise of the research project was that the deliberative forum would enable staff to share their perspectives (including promotive or prohibitive voice) on implementation strategies and arrive at an informed opinion about the strengths and weaknesses of different implementation strategies. Dental staff would then share their informed perspectives with dental management to inform the selection of implementation strategies that from staffs’ perspective were most appropriate for promoting guideline-concordant placement of treatment sealants.
The deliberative engagement consisted of several steps. First, all staff working in selected KP Dental offices attended a 15-min presentation. During this prerecorded presentation, staff received an introduction to the study, an orientation to the deliberative forum, a concise summary of the pit-and-fissure dental sealant guideline, data summarising the organisation’s adherence to the guideline regarding placement of therapeutic sealants and information about organisational barriers to improving guideline adherence. The barriers had been established during a formative evaluation that had been conducted as part of this study and involved field observations, interviews with dental leadership and focus groups with dental staff.20 Implementation strategies that had the potential to address these barriers had been identified during a theory-driven scoping review where implementation strategies were evaluated based on existing evidence of their effectiveness to address relevant challenges (see Ref 21 for the identification process and appendix for an overview of implementation strategies). This information was summarised in a workbook that stakeholders received after the 15-min presentation for self-study (see Ref 15 for an excerpt of the workbook).
Then, all staff members participated in 90-min, small-group online forums. The online forums used the Common Ground for Action (CGA) platform (https://www.nifi.org/en/cga-online-forums), where participants exchanged views in chat boxes about barriers and solutions to placing sealants for therapeutic purposes. CGA enables a recursive process during which participants receive guidance and support from professional facilitators as they make individual choices and reflect as a group on those choices. The moderators were not subject matter experts in dentistry but trained in civic engagement as is in line with protocols of deliberative engagement. An important responsibility of moderators is to provide equal opportunities for all participants to participate, regardless of professional role. Interaction in a CGA forum involves participants posting written messages to a running chat thread visible throughout the forum. As a result of the pandemic, we adapted the study design to adopt online engagement; CGA is the only available tool designed specifically to support deliberative engagement online. Finally, a survey was completed after the forum to enable staff to share their opinions about the most appropriate strategies for implementation in their dental clinics based on their opinions.
For the forum discussion, KP Dental staff were assigned to small groups with four to nine staff members each. The number of groups for each dental clinic depended on the size of the clinic. Research team members assigned clinic staff to small groups which included at least one expanded function dental assistant, at least one dental hygienist, one dentist and one other office role such as licensed practical nurse (LPN), orthodontist or front office staff per group. The rationale for assigning staff by role to small groups was to ensure that different professional roles were represented in each group, as the research team presumed different perspectives on improving guideline-concordant care would be associated with different professional roles.
Ethics considerations
KP Dental staff did not receive incentives for participation. All participants completed all research activities during their work time. Participants received an information sheet that included elements of consent and provided the opportunity not to participate in the research activity; a waiver of written consent was obtained. The study was approved by the KPNW Institutional Review Board (approval #1394486).
Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data collection
Moderators explained the forum discussion to participants using standardised text that had been prepared before the discussion sessions. The facilitators were able to draw on additional standardised prompts during the discussion but also facilitated the discussion spontaneously by responding to participants’ questions and remarks, encouraging participation and ensuring that all participants contributed equally. All exchanges during the deliberative forum were captured in transcripts that were available for download on session completion. The transcripts for qualitative analysis were randomly selected. The total number of small groups (N) for each dental clinic was randomly assigned a value from 1 to N to determine which small group to pick. The number was then assigned a letter (1=A, 2=B, 3=C, etc) for each small group within each dental clinic, and in total, 31 transcripts (two from each clinic; one clinic had only one small group) were randomly selected for analysis.
Data analysis
The chat transcripts were analysed by an experienced qualitative researcher using a directed content analysis approach.22 A directed content analysis approach is guided by existing theory, in this case the assumptions about voice and exchange of diverse perspectives during deliberative engagement described above. Based on this specific theoretical underpinning, four codes were formulated prior to the beginning of the data analysis: ‘prohibitive voice’ was defined as any expressions of participants’ concern about existing practices, behaviours, barriers, suggestions and opinions; ‘promotive voice’ was defined as any contributions that aim to improve existing work practices and procedures; ‘agreement’ was defined as any statements supporting positions taken by others or endorsement of the status quo; and ‘deferral’ was defined as deferring to the opinion of others and/or to powers beyond participants’ influence. After coding two to three transcripts using these predefined codes, additional codes were added. The final coding dictionary included four additional codes for a total of eight: ‘confusion about the forum’ was defined as any expressions that captured that participants were uncertain about the goal of the forum, ‘(critical) reflections’ were defined as any statements that captured critical thoughts about existing procedures and the deliberative engagement process, ‘other barriers’ were defined as any statements describing what participants perceived as additional barriers to the implementation of the sealant guideline, and ‘sealant guideline’ was defined as any contributions that indicated that participants were uncertain about the content of the sealant guideline or had misunderstood the sealant guideline. The coding dictionary was used to code all 31 chat transcripts that had been selected randomly. From the coded text segment, themes were derived that related to the research question.
Results
Clinic characteristics
Sixteen clinics participated in the deliberative forum discussions. The number of small groups at each clinic depended on the anticipated number of participants and is listed in table 1. In total, 363 staff members participated in the forum discussions, and 61 small group discussions were held across all clinics and steps.
Clinic characteristics: size, number of small groups and number of participants
Findings from analysis of forum chats
The directed content analysis of the chat transcripts revealed that (1) participants engaged critically with the materials prepared for the deliberative forums by sharing voice and (2) participants demonstrated limited critical engagement with each other’s ideas and opinions to identify relevant implementation strategies. We will illustrate both findings in more detail.
Participants engaged critically with the implementation strategies suggested by the research team by sharing prohibitive and promotive voice
Across most forum discussions, participants engaged with the suggested implementation strategies. After issuing their initial votes on their preferred implementation strategies, participants had the opportunity to reflect on and respond to a graphic displaying, in aggregate, the groups’ preferences related to different strategies. Participants—across all professional roles—voiced their concerns about proposed strategies and barriers.
Some staff members pointed out that placing sealants currently was not a priority. The pandemic had created a backlog of patient visits, and staff in many dental offices felt that it was important to prioritise other activities that would address this backlog. One expanded function dental assistant commented: ‘This isn’t the right time to implement anything new right now. We need to focus on access for our patients that have been waiting for stuff that is already treatment planned’.
Many staff members took issue with the implementation strategies proposed by the research team. Several strategies proposed top-down approaches such as developing implementation blueprints, obtaining written commitments by staff or involving executive boards. Many of these strategies were met with resistance: ‘I think treatment planning should be left up to the professionally trained and licensed provider, who is the one that sees what is actually going on. I don’t feel corporate pressure to diagnose outside a provider’s professional comfort zone will be well received’ (hygienist). Despite some opposition, others saw value in formalising implementation steps and appreciated being able to follow a clearly spelled-out workflow: ‘Formal implementation blueprints adds structure and order, so the workflow is more consistent and efficient. Less running around and losing time’ (dentist).
In general, many participants perceived the potential positive impact of (implementing) several implementation strategies (ie, promotive voice). This included the involvement of an expert to better identify qualifying lesions, reminders to place sealants or changes to the layout of the office:
I think changing physical structure could help. You are more likely to do the sealant if everything is readily available than if you have to go looking. I think this also includes thinking about how the treatment plan is laid out and how the appointment is structured. A well-thought-out approach to the appointment is likely to results in more adherence to the policy (Dentist)
Few participants suggested new strategies that had not been previously proposed by the researchers for facilitating the implementation of the guideline. Participants nevertheless voiced concerns that placing sealants on incipient caries would require staff to accomplish additional responsibilities without providing more time: ‘[…] resources are slim and people already feel spread thin, it can be difficult to add “ONE MORE THING” to someone’s plate’ (clinic manager). At the same time, many other participants expressed their general willingness and openness to implement change, if found necessary.
Participants also expressed their disagreement with the barriers the implementation strategies were meant to address. Many participants mentioned time and staffing as the main reason why sealants were not placed commonly. Regarding time challenges, participants described that dentists need to diagnose the need for a sealant. Usually, a dentist would only check in with a patient at the end of a hygiene visit when there was no time to place the sealant during the appointment, and patients were unlikely to return for a separate appointment only to place sealants. Other barriers mentioned included limited access to appointment times and other treatment priorities, including the limited relevance of sealants for fulfilling KP Dental’s mission for providing affordable, high-quality healthcare.
Many participants were primarily concerned about the appropriateness of placing sealants on non-cavitated caries. They were unfamiliar with the evidence, and others disagreed with the evidence, considering the risks outweighing the benefits: ‘Why do we place sealant on early caries? I think it is best to remove caries and place sealants. There are chance caries will continue to grow under sealants; that is why some providers don’t support sealant on early caries’ (dentist). Staff recognised that implementation of the guideline was incumbent on greater support of the guideline by all staff: ‘Looks to me like this is basically promotion and education regarding the guideline. People won’t follow a guideline that is either unknown or unfamiliar to them’ (dentist). Without greater support by all staff, implementation of the guideline was considered challenging.
Throughout the deliberation, participants were appreciative of the opinions of their colleagues and provided support by agreeing and highlighting valuable aspects of each other’s views. Colleagues readily backed each other in their disagreement with implementation strategies or barriers. This support and agreement could be observed across professional roles. Regardless of the role of the participant sharing their views, others readily supported their position. The readiness to support each other’s views of the implementation strategies also included participants’ interpretation and knowledge of the sealant guideline. Support for each other was displayed very consistently. This support was expressed through statements such as ‘I agree’, ‘this is true’, ‘you are very correct’, ‘100%’ or ‘ditto’.
Participants’ discussions focused largely on preventive rather than therapeutic aspects of the guideline
During the coding aimed at understanding how participants engaged voice during the deliberation, the finding that the focus of the deliberation often was not on the focus intended by the researchers emerged inductively. Many participants focused on the aspect of the guideline recommending placement of sealants on sound occlusal surfaces of permanent teeth on children as a prevention strategy. Strategies were debated how guideline-concordant care for placing preventive sealants could be improved: ‘If we had time and staff I think we all agree that sealants are a good preventive option for patients, and we all feel confident in placing them’ (expanded function dental assistant). Other suggestions included placing sealants at the time of check-up to avoid having a separate appointment, organising mini sealant clinics to place a lot of sealants on 1 day or creating lists of potential patients under 12 who were still in need of sealants. At times, participants rejected the notion that guideline adherence needed to be improved, emphasising that they readily placed preventive sealants on children.
In those instances where sealants for therapeutic purposes were debated, participants frequently raised questions or concerns about it. One hygienist wondered: ‘I don't know all our providers thoughts on placing over decay, it could be a sensitive topic?’ A dentist shared that ‘some dentists or hygienists may not believe that placing sealants over early occlusal caries is not effective or has potential to harm the patient, may feel license at stake’. This sentiment was also reflected in the statement by another hygienist: ‘I worry about placing a sealant over something that is not ‘okayed’ by a dentist as I have seen decay under sealants.’
Discussion
In this article, we explored if deliberative engagement enabled participants’ sharing of promotive and prohibitive voice about implementation strategies to promote guideline-concordant care. We found that dental professionals expressed prohibitive voice—expressions of concerns about proposed work practices—as well as promotive voice—the sharing of ideas for actions and changes to promote guideline concordant behaviour—during forum discussions and that deliberative forums may be well suited to gather staff input on proposed implementation strategies. However, the focus of the deliberation often was not as intended on deliberating sealants for therapeutic purposes but for preventive purposes. To our knowledge, the use of deliberative forums as a tool to discuss strengths and weaknesses of implementation strategies with stakeholders has previously not been analysed.
The expression of promotive and prohibitive voice in this context lays a strong foundation to develop a guideline implementation process that reflects stakeholder input and preferences as it reflects a willingness to engage critically with suggestions for implementation strategies. Employees’ openness to share their critical perspectives plays a crucial role in continuous improvement to advance organisations.23
Dental staff rejected many of the suggestions made by the research team about existing barriers and possible solutions to guideline implementation. Participants stated their reasons for considering some implementation strategies and barriers as having low value. They argued that barriers identified by the research team were not the central barriers to guideline implementation (the barriers had been identified based on formative research that included staff input) and proposed other barriers they described as more pressing. Several implementation strategies were disliked, as stakeholders argued that they emphasised top-down decision making.
While these findings tentatively support that deliberative forums can be a tool for eliciting promotive and prohibitive voice regarding the discussion of implementation strategies, our analysis also demonstrated that staff needed to enter the deliberations better prepared than they were in this case as they demonstrated limited individual and communal guideline knowledge. This finding emerged inductively during the analysis. It was included in the presentation of the findings as it had at least two important implications. First, in those instances where sealants for therapeutic purposes were deliberated, staff questioned the evidence behind the guideline and demonstrated overall little buy-in to the guideline. Staff buy-in to evidence-based care and specific guidelines is seen as crucial for successful implementation, and it has long been reported as a barrier to guideline-concordant care.24 A lack of staff buy-in to the sealant guideline hampered the deliberation as staff questioned the validity of the evidence undergirding the guideline.
Second, the discussion frequently centred on a topic not selected by the researchers for deliberation (placement of sealants for preventive purposes). Staff asserted that they were already following the guideline well (true with regard to placing preventive sealants) and, therefore, did not understand the value of further deliberating solutions. It also impacted their perceptions of the relevance of proposed solutions to implementing the guideline as the initial need to improve adherence was not recognised.
There had been several opportunities for staff to learn about the content of the guideline prior to the deliberation as deliberative engagement involves providing participants with resources that support their process of becoming more informed about a given issue. We attempted to increase forum participants’ familiarity with the issues by delivering a 15-min introductory session, by providing a workbook that was structured to encourage active engagement with the material and by embedding into the online CGA platform resource materials available to the participants on demand.
As described above, despite these resources, forum participants had limited knowledge of the guideline content. This suggests that the distribution of educational materials may not have been sufficient to affect knowledge about the guideline; an assumption supported by previous research.25 Personal motivation to learn about the subject matter may also have played a role in participants’ readiness to study the workbook prior to the deliberation. Another tool to support that deliberations stay on topic is the presence of subject matter experts to correct factual mistakes or address any questions participants may have about a topic of debate.26 27 This was not feasible in this context, where guideline implementation was deliberated by 61 small groups over several months. It is also uncertain if expert intervention would have been meaningful and effective to achieve improved familiarity with the pit-and-fissure dental sealant guideline.
The participants’ limited knowledge of the pit-and-fissure dental sealant guideline was not critically assessed by colleagues during the deliberation. Participants readily supported each other, their positions and their reasoning regardless of the focus of the deliberation and their professional roles and hierarchies. The lack of different opinions could be related to the topic of the deliberation, that is, there may not have been any difference of opinion among them. Possibly, not all knowledge that participants had about the pit-and-fissure dental sealant guideline was always shared. Or, alternatively, there may have been difference of opinion that we failed to elicit. There may have been something about the format of the deliberation, where coworkers were brought together to deliberate a topic, that stifled expression of different opinions. This could be explored further in future research.
Usually, in deliberative forums, members of the public who do not know each other are brought together to deliberate a topic they care about. For this research project, we asked coworkers who see each other almost daily at work to engage their difference with regard to the pit-and-fissure guideline. This may have influenced the deliberation as people who have ongoing professional relationships with each other may find it more difficult to critically engage with each other’s assumptions and knowledge. Bringing together staff from different dental clinics rather than the same dental clinics may have offered a productive solution. This, however, would make it more challenging to discuss clinic-specific implementation strategies and barriers.
There are several limitations to our research. We did not analyse all available chat transcripts but randomly selected about half of the transcripts for analysis. We examined if deliberative forums enabled participants to share promotive and prohibitive voice about implementation strategies in one organisation and regarding one guideline only. It is possible we would have obtained different results if we had conducted the study in organisations with different cultures and another guideline. The deliberative forums had initially been planned as in-person events. Due to COVID-19, the study team pivoted to organise the forums as an online chat forum. This may have impacted participant involvement and ability to provide input or engage with each other. Finally, staff were able to participate in the introductory presentation and deliberative forum during their work time; however, no specific time was reserved for review of the workbook.
The use of deliberative forums to engage stakeholders in the selection of implementation strategies should be explored further in future research. Sharing information about the guideline and guideline-concordant care prior to the deliberation is an important step of the deliberation process. Exploring ways of sharing this information effectively is crucial for ensuring that a deliberation is informed by the latest evidence and remains relevant. It is also important to better understand why we found little evidence of diverse perspectives on the value of implementation strategies. Did participants all share the same perspective, or does bringing together colleagues from the same workplace hinder critical engagement with each other’s perspectives? Future research may look to discover whether the dynamics of selective critical engagement exhibited in this study change when people from different dental clinics engage in deliberation.
Conclusion
In conclusion, the deliberative forum discussions enabled staff to share promotive and prohibitive voice while discussing implementation strategies and barriers to guideline-concordant care. Critical engagement was oriented, however, towards the materials that the research team had put together, rather than with each other’s positions and opinions. To ensure a deliberation that was more oriented towards discussing implementation strategies to improve sealant placements on incipient caries on occlusal surfaces, greater familiarity with the guideline would have been important for staff, as well as more intimate knowledge of the current discrepancies in guideline-concordant care. While this information had been shared with dental staff prior to the deliberation, it had not been impactful enough for staff to influence the deliberation. Expert intervention and additional training to encourage facilitators to draw out differences among participants could have been a possible tool to shape the deliberation process in ways more oriented towards the stated goal of the deliberate discussions.
Supplemental material
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Kaiser Permanente Northwest Institutional Review Board #1394486.
Acknowledgments
The authors would like to thank KP Dental and all staff members for participating in this research study.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors IG analysed the chat transcripts and wrote the manuscript and act as guarantor for the overall content of the manuscript. TD designed and planned the deliberative forums. DJP, SR and JLF contributed to implementing the DISGO study at KP Dental. CDK supported the analysis. DEP planned and designed the DISGO study and obtained funding. All authors reviewed the manuscript.
Funding This work was supported by the National Institutes of Health through a cooperative agreement (1U01 DE027452-01) from the National Institute of Dental and Craniofacial Research (NIDCR).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.