DEBATE Open Access Unintended consequences and challenges of quality measurements in dentistry Enihomo M. Obadan-Udoh 1* , Jean M. Calvo 2 , Sapna Panwar 1 , Kristen Simmons 3 , Joel M. White 1 , Muhammad F. Walji 4 and Elsbeth Kalenderian 1 Abstract Background: In recent years, several state dental programs, researchers and the Dental Quality Alliance (DQA) have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences. Some of these measures have been tested and validated for various population groups. However, there are some unintended consequences and challenges with quality measurement in dentistry as observed from our previous work on refining and transforming dental quality measures into e-measures. Main body: Some examples of the unintended consequences and challenges associated with implementing dental quality measures include: a de-emphasis on patient-centeredness with process-based quality measures, an incentivization of unethical behavior due to fee-for-service reimbursement systems, the risk of compromising patient and provider autonomy with plan-level measures, a disproportionate benefits of dental quality measurement going toward payers, and the risk of alienating smaller dental offices due to the resource-intensive nature of quality measurement. Conclusion: As our medical counterparts have embraced quality measurement for improved health outcomes, so too must the dental profession. Our ultimate goal is to ensure the delivery of high quality, patient-centered dental care and effective quality measurement is the first step. By continuously monitoring the performance of dental quality measures and their continued refinement when unintended consequences are observed, we can improve patient and population health outcomes. Keywords: Ethics, Quality, Dentistry, Quality measures Background From the early debates of an elitist profession bewildered by the advent of quality assurance and the reluctance to subject one’ s practices to external scrutiny [1, 2] to the widespread prevalence of accreditation standards that serve as prerequisites for acceptance into the dental pro- fession, [3–6] quality in dentistry has come a long way since its inception. While quality assurance is essential for ensuring the efficacy and effectiveness of dental interven- tions, it lacks the holistic and systems level focus that encourages continuous learning from engendering small changes to creating lasting solutions [7]. Quality improve- ment (QI), made popular by the Institute of Healthcare Improvement (IHI) through initiatives such as the Triple Aim [8], and furthered through efforts by the Joint Commission, has become the hallmark of forward-lean- ing healthcare institutions and learning healthcare sys- tems [9, 10]. One crucial aspect of QI is the utilization of standardized measures of structure, process, and out- comes to assess performance and evaluate system changes [10, 11]. For the dental profession to keep pace with the healthcare system in the United States, there must be a shift from dentistry’ s traditional understanding of quality systems encompassing risk management, quality control and quality assurance, to continuous QI through stan- dardized measurement [12–14]. In recent years, several state dental programs, researchers and the DQA - a team of dental stakeholders representing payers, educators, professional organiza- tions, federal agencies, providers and the public, have sought to develop baseline quality measures for dentistry * Correspondence: Enihomo.obadan-udoh@ucsf.edu 1 Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, 707 Parnassus Avenue, San Francisco, CA 94143, USA Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Obadan-Udoh et al. BMC Oral Health (2019) 19:38 https://doi.org/10.1186/s12903-019-0726-4