Open Journal of Stomatology, 2013, 3, 497-503 OJST
http://dx.doi.org/10.4236/ojst.2013.39081 Published Online December 2013 (http://www.scirp.org/journal/ojst/)
Patient Experiences of Medical Screening Performed by
the Dental Services: A Qualitative Study
Göran Friman1,2*, Ghazaleh Golestani3, Awara Kalkali4, Inger Wårdh1, Margareta Hultin5
1Department of Dental Medicine and Academic Centre of Gerodontics, Karolinska Institutet, Stockholm, Sweden
2Department of Health and Environmental Sciences, Karlstad University, Karlstad, Sweden
3The Swedish Dental Service Organizations, Stockholm County AB, Stockholm, Sweden
4The Swedish Dental Service Organizations Västra Götaland, Gothenburg, Sweden
5Department of Dental Medicine/Division of Periodontology, Karolinska Institutet, Huddinge, Sweden
Received 30 October 2013; revised 1 December 2013; accepted 13 December 2013
Copyright © 2013 Göran Friman et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objective: To explore how medical screening per-
formed by the dental service was perceived from the
patient’s perspective. Material and methods: Medical
screening for high blood pressure and high plasma
glucose was performed on 170 patients at a dental
clinic in a small town in central Sweden. Seventeen
individual interviews were conducted with a strategic
sampling of these patients. The interviews were re-
corded and transcribed. The transcriptions were cod-
ed and categorized in a manifest analysis, followed by
a latent, interpretive analysis. Results: The manifest
analysis resulted in three categories: Positive attitude
to screening and dental professionals which need to
have specific knowledge of medical screening; Dental
care which provides continuity but is not a neutral
environment; and Feedback on the medical screening
results and desired cooperation between dental and
health care services. The latent analysis pointed out
the importance of the patient’s feeling that the proce-
dure is carried out properly and safely, and requests
for clear feedback concerning the results of the screen-
ing. Conclusions: The interviewees experienced the den-
tal care service as providing continuity. They would
like to have regular medical screenings at their regu-
lar dental appointments to identify risks of cardiovas-
cular diseases and diabetes. However, they expressed
that it was important for the dental care staff to have
the necessary medical knowledge. They also wanted
good cooperations between the dental and health care
services, with clear feedback to the patients about
both positive and negative results and, when appro-
priate, referrals to the health care service.
Keywords: Diabetes; Hypertension; Medical Screening;
Patient Satisfaction; Risk Assessment
1. INTRODUCTION
Many individuals have undiagnosed type 2 diabetes [1,2]
or undiagnosed hypertension without symptoms [3]. Di-
agnoses are often not recognized until complications
arise [4].
One third of individuals with type 2 diabetes are un-
diagnosed [2,5]. Even in a pre-diabetic condition, there is
an increased risk of complications such as cardiovascular
disease. Early diagnosis is important for successful and
cost-effective treatment [6].
Hypertension, a global problem, was noted in 26.4%
of the adult population in 2000 and is predicted to in-
crease by about 60% in 2025, from 972 million to 1.56
billion [7], with ischemic heart disease and cerebrovas-
cular disease being the leading causes of death world-
wide [8]. Both diabetes and cardiovascular disease show
correlations to oral health, in particular periodontal dis-
ease [9,10].
In many countries, dentists follow their patients on a
regular basis. In 2010-2011, 72.7% of the adult Swedish
population had dental appointments [11]. Among Swedes
aged 50 and above, 81% reported having seen a dentist in
the preceding year, data from 2007 [12].
This opportunity to identify both oral and general risk
factors explains why medical screening has recently been
introduced and recommended in dentistry [13,14]. In a
quantitative study of patient experiences, all the respon-
den ts expressed a favourable attitude to cha ir-s ide scr een-
ing [15]. However, to our knowledge no qualitative stud-
ies have been performed concerning medical screening
for both blood pressure and plasma glucose, but for
*Corresponding a uthor.

G. Friman et al. / Open Journal of Stomatology 3 (2013) 497-503 498
diabetes screening only [16].
In a small town in central Sweden, medical screening
for blood pressure and plasma glucose was offered con-
secutively to 207 regular adult dental patients at their
annual check-up, of whom 170 agreed to participate.
Thirty-nine patients were referred to health care as pos-
sibly at risk of hypertension or diabetes, and 24 of these
received further medical treatment or lifestyle recom-
mendations [17].
The aim of the present study was to explore how this
medical screening was perceived from the patient’s per-
spective.
2. MATERIAL AND METHODS
2.1. Ethics Statement
The study is approved by the Regional ethical review
board in Uppsala, Sweden, in accordance with the ethical
standards and with the Helsinki Declaration of 1975, as
revised in 1983. The participants received both verbal
and written information about the study and that they
were not compensated for their time, all of them gave
their written informed consent to participate sent by post.
2.2. Procedure
This qualitative study was based on individual interviews.
It was conducted from March to May 2010 in a neutral
venue not adjacent to th e dental clinic in the town where
the medical screening was performed.
Twenty-eight patients who underwent medical screen-
ing at the dental clinic in addition to their dental exami-
nation were asked in a personal letter to p articipate in an
individual interview. They were selected strategically to
maximize the variety of data in terms of age, gender, pro-
fessional background and results of the medical screen-
ing.
The interviews were conducted by one of the authors
(AK) with open-ended q uestion s from an interview gu id e
focusing on two main areas:
 How did the patients experience medical screening
performed by dental profes sionals ?
 How do the patients perceive regular medical screen-
ing when integrated into the regular dental examina-
tion?
The study process was inspired by Grounded Theory
and the interviewees were asked to freely describe their
experiences and opinions in conversational style [18].
When necessary, the interviewer asked additional ques-
tions for clarification. The interviews lasted approxi-
mately 25 - 40 minutes and were audio taped and tran-
scribed verbatim by another author (GG). The transcrip-
tion process was successively performed in the same
order as the interviews. This procedure made it possible
to check whether the interview guide or the interviews
needed to be su pplemented [18]. After 17 interv iews, the
authors concluded that no new relevant information
emerged, saturation was reached [18] and the data col-
lection ended.
2.3. Analysis
As the study material did not have the prerequisites to
entirely follow the Grounded Theory method, data was
treated like a model similar to qualitative manifest and
latent content analysis [19]. The interview texts were
read in their entirety by the authors and divided into
groups of meaning-bearing units, codes. Similar codes
were merged and then sorted into subcategories and
categories. A comparison was made with the interview
guide to see if the categories corresponded to the ques-
tion areas. This represented the manifest level of analysis.
Then the authors looked for a main category or a theme,
the latent content analysis.
The analysis was illustrated with quotations. The
quotes presented in this article are typical of the views
expressed by the interviewees and are used to exemplify
the categories and theme.
3. RESULTS
Of the 28 selected potential interviewees, 19 agreed to
participate. The reasons for not participating were: three
were “out of town”, three “forgot how the screening was
conducted” and three did not reply. Two of the partici-
pants then failed to appear for the agreed interview: one
had decided not to participate in the study and the other
failed to appear for the interview and then could not be
reached either by phone or letter. Seventeen patients
were ultimately interviewed (Table 1).
Meaning-bearing units were extracted from the texts,
and codes, subcategories and categories were formed
(Table 2). Figure 1 gives a visual presentation of the
findings. The analysis revealed three categories made up
of a number of subcategories. One theme permeated
Table 1. Characteristics of study material. Values are number of
participants if not otherwise stated.
Study material Medical screening
N (%) Interview n (%)
Samples 207 28
Dropouts 37 11
Participants 170 (100) 17 (100)
Men 76 (44.7) 9 (52.9)
Women 94 (55.3) 8 (47.1)
Mean age 63.95 66.05
Referred for health care 40 (23.5) 7 (41.2)
Required health care or
lifestyle recommendations 23 (13.5) 4 (23.5)

G. Friman et al. / Open Journal of Stomatology 3 (2013) 497-503 499
Table 2. Examples of meaning-bearing units, codes, subcategories and categories.
Codes Subcategory Category
Codes and subcategories describing the category “Positive
attitude to screening but dental profe ssiona ls need to have
specific knowledge of medical screening”
Positive view on screening
Prevent potential noncommunicable diseases
Insight into a possible link between general and oral health Positive attitude to screening Positive attitude to screening but dental
professionals need to have specific
knowledge of medical screening
Equal sampling standard by health care as by and dental
professionals
Similar education and training Professional skills in medical screening
Requires proper knowledge
Prepared to pay the same for the service Willingness to pay
Codes and subcategories describing the category “Dental
care provides continuity but is not a neutral environment”
Dental regularity and continuity
Different doctors, usually the same dental professional Dental care provides continuity Dental care provides continuity but is not a neutral environment
Reluctance to seek medical attention
White coat hypertension
Dental fear Risk of erroneously high blood pressure in the dental environment
Codes and subcategories describing the category “Feedback
about the medical screening results and desired cooperation
between dental and health care services”
Getting a response about their health Feedback about the medical screening
results
Feedback about the medical screening
results and desired cooperation between
dental and health care services
The dental care service becomes a link Integrated dental and health care
Referral to health care
Collaboration or integration between dental and health care
Dental professional cannot make a medica l diagnosis
Figure 1. Patient experiences of medical screening performed by the dental care service, as
described in three categories and one theme.

G. Friman et al. / Open Journal of Stomatology 3 (2013) 497-503 500
them all. Below, these results are presented in greater
detail.
3.1. Manifest Analysis
Positive attitude to screening but dental professionals
need to have specific knowledge of medical screening
This category included the subcategories “positive at-
titude to screening”, “professional skills in medical
screening” and “willingness to pay”.
All interviewees had positive thoughts and opinions
about undergoing medical screening at a dental clinic.
Some also had some insight into a possible relationship
between general health and oral health, which made them
even more interested in a screening.
It’s good that the dentist does a medical screening
since there may be a relationship between the two. And I
guess there’s something to the idea that teeth and things
affect the rest of one’s body. If medical screening can
prevent diseases and injuries in time, that’s definitely an
advantage.
The interviewees felt it was important for the dental
care staff to have adequate knowledge if they were going
to do medical screening, and also stated that there was no
difference between dental and health care staff when it
came to the practical performance of the screening.
Actually I thought they were just as professional as at
the doctor’s office. I didn’t experience any difference. In
my opinion, he has, I guess, as I see it, they are basically
trained in similar ways.
The interviewees were willing to pay for this service.
Since they paid at the health care service, they could just
as well pay the same at the dental care service.
I don’t mind paying, since I uh, go to the health center
and then I have to go there. And pay for it. So uh, if the
price is the same.
Dental care provides continuity but is not a neutral
environment
This category included the subcategories “dental care
provides contin uity” and “risk of erroneou sly high blood
pressure in the dental environment”.
Many interviewees remarked that they go to their den-
tist yearly, and usually see the same dentist, so they go
there more often than to the doctor, which made medical
screening by the dental service seem convenient.
You always see a different doctor, but usually the same
dentist. I think lots of people go to the dentist more regu-
larly than to the doctor.
The advantages of dental regularity and continuity
were stressed by several interviewees, who pointed out
that some people are reluctant to seek medical attention.
They neglect their symptoms. Dental care can help iden-
tify patients at risk with this screening.
I go to the dentist more often than the doctor. So this is
a good way for me to get checked, you might say.
On the other hand I would be glad to have it discov-
ered in time because then I would actually be able to do
something about it.
Some of the interviewees mentioned that it was im-
portant for the dental services to consider source of error
in blood pressure sampling. They pointed out an uncer-
tainty in pressure measurement when they had a high
value at the clinic but a normal value when their blood
pressure was taken at home or after rest at the health
center. Some interviewees could not remember any pe-
riod of rest before their blood pressure was taken, but
said that it was just the same as at the doctor’s office.
When they take your blood pressure when you are
there to see the dentist and are a little nervous, then it
will be higher. That’s a natural reaction. In fact it always
goes up when you are the dentist’s or the doctor’s office.
It would go up a little bit in any case.
Feedback about the medical screening results and
desired cooperation between dental and health care
services
This category included the subcategories “feedback
about the medical screening result”, and “integrated den-
tal and health care”.
The interviewees emphasized the importance of get-
ting a response about their health through feedback after
the screening. They pointed out that if medical screening
were included in the annual den tal appointment, it would
be important to receive feedback.
Well, nothing ha ppen ed a fterwa rds. So I think that was
one thing, getting no follow-up. I don’t know what hap-
pened. If I had had high blood glucose I don’t know if
there would have been follow-up, either.
It was not clear to everyone as to whether there was
established collaboration between the dental and health
care services. Therefore, many interviewees pointed out
such collaboration needed to be established before medi-
cal screening in dental settings could be introduced, and
they even suggested integration between dental and
health care.
I don’t really understand why there is a distinction be-
tween the health care and dental services.
If plasma glucose and blood pressure are checked by
the dental care services, this should certainly make things
easier for the health care staff and if necessary, the dental
care service can send a referral to health care so the pa-
tient gets a new health care contact. In other words, the
dental care services become a link. The interviewees
considered that close collaboration was especially bene-
ficial when disease symptoms are neglected.
Well, I think I’d get help faster with a referral. It
would be sent to my doctor, like. Which would make
things happen better than if I tried to work it out myself.
I’d see it as a good thing if they sent a referral—di-
rectly…of course there may be people who…would

G. Friman et al. / Open Journal of Stomatology 3 (2013) 497-503 501
rather themselves…make the contact but I don’t see…
any disadvantage about it.
Not all but most of the interviewees were aware that
the dental care services cannot make a medical diagnosis.
3.2. Latent Analysis
Medical screening in dental settings implies responsi-
bility, which requires effective cooperation between the
dental and health care services
The latent analysis revealed that introducing medical
screening in a dental care setting is a responsibility that
requires good collaboration between the dental and
health care services. Some interviewees in this project
felt that the collaboration was not completely clear to
them.
When the patient’s screening values exceeded thresh-
olds for disease risk, these at-risk patients would have
the opportunity, if the dental care service referred them
to the health care service, to receive health care earlier
without having to contact the health care service them-
selves. The referral would result in a smoother and easier
handling of their cases. However, it was important to the
interviewees to experience the procedure as being carried
out properly and safely.
Some interviewees pointed out a feeling of insecurity
in the lack of feedback and information about their test
results. Many felt that they were not informed whether
they had elevated values. All interviewees requested
clear feedback if a medical screening were to be intro-
duced in the dental care. Others realized that they proba-
bly would have been notified if they were at risk of dis-
ease.
When they did the diabetes test I thought, uh, well, if
they found anything I do hope they would call and tell me.
Yes, and that there has to be a link to the health centre or
something, with the dentist.
Finding out that you are at risk of disease or possibly
already have a disease was not negative, according to the
interviewees. They all felt it didn’t matter whether this
information came from the dental or medical services.
The most important thing was that they found out. All
interviewees realized that medical screening could lead
to early disease detection.
There can’t be anything negative about finding out
that you’re sick.
The attitude of the interviewees to the dental care ser-
vices taking responsibility for their general health was
positive, and they pointed out benefits of undergoing
medical screening at the dentist’s office. However, one
person out of the seventeen felt that this was not the re-
sponsibility of the dental service.
4. DISCUSSION
In the present study, it was revealed that all interviewees
had a generally positive attitude to undergoing medical
screening as part of their regular dental examinations.
Dentists’ attitudes to medical screening as a part of the
dental examination have also been reported to be positive
[16,20].
4.1. Method Discussion
It is important to achieve trustworthiness in a qualitative
study [19]. Both authors GF and IW have completed
education in qualitative methodology and IW has ex-
perience from conducting several qualitative studies. To
assure credibility [19], the interviewer in the present
study was a person unknown to the participants and the
interviews were conducted in a neutral venue not adja-
cent to the dental clinic.
There was a strategic selection of participants and the
sampling continued until the authors concluded that no
new information emerged, although there were very few
negative comments from the interviewees. The dental
clinic at which the screening was carried out has indi-
vidualized prophylactic care programs, and some inter-
viewees may have been informed in that context about
possible relationships between oral health and general
health. All interviewees had previously agreed to un-
dergo medical screening. These factors and the fact that
some of the interviewees were referred to the health care
services after the medical screening, where they were
given further treatment and/or lifestyle recommendations,
may have helped them to understand the benefits of the
process of medical screening. It is possible that some of
the individuals who declined to participate might have
had a negative attitude abo ut medical screening. Another
choice of method, for example an anonymous postal
questionnaire to all those who participated in the screen-
ing, might have been more effective at capturing nega-
tive attitudes [15].
The researchers made their analyses as quickly as pos-
sible after the data collection to minimize the risk of
changes in the researchers’ interpretations, to increase the
dependability [19]. After each interview, the interview
process was evaluated to secure relevant data for the next
interview.
Accurate written description of the research process
and the context was made to pursue transferability [19]
and to give the reader the ability to evaluate whether
these findings are transferable to other contexts.
4.2. Result Discussion
All but one of the interviewees in th is study was positive
to the procedure with medical screening in dental set-
tings and was willing to pay for this service. They ap-
preciated the continuity the dental services provide and
expressed some dissatisfaction with the absence of such

G. Friman et al. / Open Journal of Stomatology 3 (2013) 497-503 502
continuity in Swedish health care. Similar positive re-
sults are revealed in qualitative studies of patients’ atti-
tudes toward diabetes or HIV testing in dental settings
[16,21]. A questionnaire study among adults with diabe-
tes in Great Britain [22] revealed that 53.5% of the par-
ticipants supported dentists’ involvement in diabetes
screening and that 20.9% would be willing to pay for
diabetes screening in a dental setting. In the opinion of
the authors, this relatively low interest in medical screen-
ing in Great Britain may be attributable to poor aware-
ness of the importance of oral self-care and limited
awareness of the oral health complications associated
with diabetes.
Our interviewees can be regarded as quite well in-
formed about both oral and general health. They had
formulated demands and expectations if medical screen-
ing were to be introduced in dental care and thought it
was self-evident that a dentist has a responsibility to have
adequate medical knowledge before undertaking such
testing. Dentists have requested training and information
about practical procedures if medical screening is intro-
duced [20]. Well-established cooperation with the health
care services is equally important for optimal manage-
ment of patients after screening. It was especially pointed
out by several of the interviewees as a major advantage
that the dental service provides this contact in the form
of a written referral in case of exceeded threshold values.
This is the responsibility of the dental service, but den-
tists are not qualified to make medical diagnoses. The
aim of medical screening performed by the dental care
service is to identify patients at risk.
As pointed out by the interviewees, this kind of
screening could result in false positive results concerning
high blood pressure because of “white coat syndrome” in
a somewhat intimidating dental environment. This could
lead to both unnecessary appointments, overloading the
health care system, and unnecessary anxiety in some
patients about their health status. However, studies from
the US indicate that high blood pressure at the dentist’s
office may have other, more relevant, causes and that
such patients would benefit from further investigation
[23].
The interviewees pointed out the importance of feed-
back and knowledge of the results of the medical
screening. Even those in terviewees whose results did not
exceed the threshold values for disease risk wanted to
receive both oral and written information about their
scr eening results.
Medical screening in dental settings may help indi-
viduals with unknown high blood pressure and/or high
plasma glucose levels to receive early medical help. This
could also be seen in a broader perspective of public
health, although th e present results are only app licable in
their own and possibly similar contexts.
5. CONCLUSION
The interviewees experienced the dental care service as
providing continuity. They would like to have regular
medical screenings at their regular dental appointments
to identify risks of cardiovascular diseases and diabetes.
However, they expressed that it was important for the
dental care staff to have the necessary medical knowl-
edge. They also wanted good cooperations between the
dental and health care services, with clear feedback to
the patients abou t both positive and neg ative results and,
when appropriate, referrals to the health care service.
6. ACKNOWLEDGEMENTS
The authors would like to thank Comprendo i Tidafors and Linda
Schenck for the English language editing.
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