Scientists Redefine Quality in Oral Healthcare With First Co-Designed European Definition

What does it actually mean for dental care to be good? For decades, the answer has depended on whom you ask. A dentist may point to clinical outcomes, a policymaker to cost-effectiveness, and a patient to whether they were treated with dignity and without pain. That fragmentation, researchers argue, has quietly undermined efforts to fix one of the most persistent problems in global health: oral diseases remain among the most common conditions on earth, yet the quality of the care meant to prevent and treat them has never been coherently defined. A new study published in Health Research Policy and Systems now offers a way out of that impasse, presenting the first definition of oral healthcare quality that was deliberately co-developed with the clinicians, policymakers, and patients who must live with its consequences.

The research, led by Michael Lorenz and Stefan Listl of Heidelberg University together with Ziade Sarroukh of Radboud University Medical Center, was conducted as part of the European Union-funded DELIVER project. Its starting point is deceptively simple: you cannot systematically improve something you have not collectively defined. Quality improvement interventions, the authors contend, require a shared understanding of what quality means and a normative direction that tells stakeholders where improvement efforts should be headed. Without that foundation, initiatives launched by different actors pull in different directions, resources are wasted, and vulnerable populations who already struggle to access care continue to be left behind.

The burden that motivated the work is substantial. Oral diseases impose a heavy toll on societies, both in human and economic terms, and access to oral healthcare remains unevenly distributed, with disadvantaged groups facing the greatest barriers. There is, the researchers note, renewed political will at the level of the United Nations to extend Universal Health Coverage to oral health, a development that could bring care to millions who currently go without. But expanding coverage without addressing quality, they warn, risks scaling up services that are inequitable, unsafe, or simply ineffective. Solving these intertwined problems, the study argues, requires coherent efforts that span multiple stakeholders and sectors, and that coherence begins with language.

To build that shared language, the team designed a structured five-step co-development process. First, they carried out a literature screening to identify the themes that scientific studies associate with the quality of oral healthcare. Second, they compiled those themes into a starting list that could anchor subsequent discussions. Third, they convened World Café sessions, a deliberative format in which participants rotate through small-group conversations, allowing ideas to be debated, refined, and built upon in a way that large formal meetings rarely permit. These sessions brought together oral healthcare providers, policymakers, and patients from across Europe, ensuring that the definition would reflect not only technical expertise but also lived experience and administrative reality.

The fourth step applied thematic analysis to the rich information generated in the World Café sessions, systematically coding and synthesizing what participants had said. Finally, the process closed with voting and completion, allowing the consortium to converge on a formulation that every stakeholder group could endorse. The researchers reported the study in accordance with the Consolidated criteria for reporting qualitative studies, known as COREQ-32, a transparency standard designed to make qualitative research methods visible and assessable. The work received ethics approval from the Medical Faculty of Heidelberg University, and all participants provided informed consent, underscoring the methodological rigor behind what might otherwise appear to be a purely discursive exercise.

The definition that emerged is both ambitious and precise. Quality oral healthcare, the consortium agreed, refers to the contribution of healthcare to optimal oral health. That contribution, in turn, entails that care alleviates oral health inequity, is comprehensive, empowers patients, mitigates harm and encourages learning systematically, improves well-being, minimizes the waste of resources, and is provided at the right time. To maximize quality, the definition continues, care should be equitable, accessible, patient-centered, safe, effective, efficient, and timely. Each clause condenses an enormous body of health services research and stakeholder deliberation into actionable language, and the seven closing attributes deliberately echo the widely used Institute of Medicine framework for healthcare quality while extending it with explicitly equity-oriented and patient-empowering dimensions.

What makes the definition scientifically significant is not only its content but its provenance. According to the authors, it is the first definition of oral healthcare quality that was co-developed together with providers, policymakers, and patients from various European countries. That participatory pedigree matters for a practical reason: definitions imposed from above tend to stall at the implementation stage, because the people expected to act on them were never invested in their creation. A definition forged through deliberation, by contrast, carries what the researchers call meaningful normative directionality. It tells practitioners, system managers, and patient advocates not merely what quality is but in what direction improvement should move, giving divergent actors a common compass for collective problem-solving.

The definition is explicitly designed as a foundation for operationalization rather than an end in itself. The authors describe it as the basis for developing targeted quality indicators and improvement interventions at three distinct levels: the practice level, where individual dental teams design and deliver care; the community level, where prevention programs and local services shape oral health outcomes; and the health systems level, where financing, regulation, and policy determine who gets care and how good that care can be. In other words, the definition is meant to cascade downward into measurable indicators, which can then be used to benchmark performance, identify gaps, and evaluate whether interventions actually make care more equitable, safer, and more efficient.

That cascading logic is where the study’s implications become potentially far-reaching. Oral health has long been the poor relation of health systems research, often excluded from universal coverage schemes and quality frameworks that focus on general medical care. By anchoring oral healthcare quality in a definition co-owned by multiple stakeholder groups, the DELIVER consortium has created a conceptual tool that could inform national quality strategies, professional guidelines, and patient-facing standards across Europe and beyond. The timing is pointed: as UN member states debate extending Universal Health Coverage to oral health, governments will need exactly the kind of agreed-upon quality framework this definition provides to ensure that newly covered services meet a meaningful bar.

For the researchers, the deeper lesson is methodological. Complex, systemic problems in health care are rarely solved by technical fixes alone; they require the alignment of values, incentives, and understandings across the many actors who constitute a system. The five-step process piloted here, combining systematic literature screening with deliberative World Café workshops and structured consensus voting, offers a replicable template for other fields grappling with similarly contested concepts, from mental health service quality to long-term care standards. The study’s conclusion is understated but consequential: a shared, actionable definition of quality is a key enabler of quality improvement itself. In a field where millions of people suffer preventable pain, inequity, and ineffective treatment, agreeing on what good care means may prove to be the most quietly radical intervention of all.

The study’s transparency apparatus extends beyond the COREQ-32 checklist itself. The published supplementary material documents the full audit trail of the consensus process, including an overview of the literature review with its search strategy and results, the initial topic list that served as supporting material in the workshops, sensitivity checks on the voting results, and a detailed breakdown of non-researcher participants by country and stakeholder group. This level of documentation allows readers to trace how each element of the final definition was anchored in evidence and deliberation, and to assess whether particular stakeholder groups or countries were over- or under-represented in shaping the outcome.

Institutionally, the work sits at the intersection of two research environments: the Section for Oral Health at the Heidelberg Institute of Global Health, part of Heidelberg University Hospital, and the Department of Dentistry, Quality and Safety of Oral Health Care at Radboud University Medical Center in the Netherlands. The DELIVER project, within which the study was embedded, received funding from the European Union’s Horizon Europe Research and Innovation Program under grant agreement 101057077, and the open access publication fee was supported through Projekt DEAL with additional acknowledgment of Heidelberg University. The article was published as open access under a Creative Commons Attribution 4.0 International License, meaning the definition and its supporting materials can be freely reused, adapted, and distributed with appropriate credit, a licensing choice that lowers the barrier for health systems and professional bodies seeking to adopt the framework.

The publication record also reflects the compressed timeline typical of modern rapid-access publishing. The manuscript was received in February 2026 and accepted in September of the same year, with the version shared online carrying a permanent digital object identifier that makes it citable even before the final Version of Record replaces it. For a field in which contested concepts often stall in committee for years, the combination of a structured deliberative method, documented consensus checks, and immediate open availability positions this definition to be tested, criticized, and refined by the very communities it was designed to serve.

Subject of Research: Co-development of an actionable definition of oral healthcare quality with providers, policymakers, and patients in Europe

Article Title: Reconsidering how we define quality: insights from the co-development of an actionable definition of oral healthcare quality,mntion

Article References: Lorenz, M., Sarroukh, Z., & Listl, S. (2026). Reconsidering how we define quality: insights from the co-development of an actionable definition of oral healthcare quality,mntion. Health Research Policy and Systems. https://doi.org/10.1186/s12961-026-01536-8

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01536-8

Keywords: oral health, quality of care, co-development, definition, World Café, deliberative methods, Universal Health Coverage, health equity, quality indicators, Europe, patient-centered care, health systems