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Abstract
Introduction The integration of dental services within the broader healthcare landscape is crucial for achieving integrated healthcare delivery. However, we lack a clear representation of the full spectrum of possible dental service integration, which is necessary for policymakers, healthcare system organisers, researchers, professionals and patients themselves to optimise organisations. Our present research aims to establish the foundation for a taxonomy of dental services that is fully integrated into the health domain, while minimising historical, cultural or epistemological biases.
Methods and analysis This protocol outlines a scoping review that will adhere to the framework of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. It has also been registered on the Open Science Framework. The research team, including a patient representative, advocate and transdisciplinary researcher, who has been involved from the inception, describes a two-phase dynamic screening process. An initial search will be conducted in the PubMed database using a Boolean search strategy based on theoretical frameworks that view health through a biopsychosocial continuum. New taxa will be progressively identified, and in the second phase, we will develop a new search strategy based on the results obtained and will explore deeper into certain categories or subcategories of taxa. Iterative strategies may also involve using new databases and even grey literature. This process will be repeated until taxon saturation is achieved and will be updated prior to submission to capture the latest literature, ultimately resulting in a comprehensive taxonomy, at the scale of individual healthcare pathways (micro- and meso-levels of organisation).
Ethics and dissemination This scoping review will analyse published secondary data and does not require ethical review. The findings will be disseminated through publication in scientific journals, presentation at conferences and sharing through professional networks.
- Delivery of Health Care, Integrated
- Health Services
- ORAL MEDICINE
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The primary strength of this scoping review will be to map the patterns described in the literature as dental service integration, at the scale of individual healthcare pathways (micro- and meso-levels of organisation).
Another strength of this review will be its effort to minimise historical, cultural and epistemological biases in the consideration of dental service integration, by grounding the research strategy in theoretical models, extending beyond the specific field of dentistry.
To ensure a rigorous and transparent methodological process, this review will adhere to (1) the framework outlined by the Joanna Briggs Institute and (2) the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
The scope of this scoping review will not include assessing the quality of the included articles, evaluating the efficacy of various identified dental service integration modalities or quantitatively assessing the relative proportions of various dental services within the taxonomy.
A limitation of this review will be the exclusion of the macro-systemic level of analysis of dental service integration, which would involve specific meta-research on healthcare systems and the interplay between policy, society, and the healthcare sector.
Introduction
The process of medical specialisation has been evolving for several centuries, resulting in an increase in the number of medical specialties.1 This evolution can be attributed to various factors, including changes in the conceptual approach to disease, industrial development as well as socioprofessional or socioeconomic challenges.1
With the diversification of medical specialties and related professions, the necessity arose to interconnect healthcare professions. The interconnection of medical activities ensures that patients can be cared for by healthcare professionals ideally collaborating to provide optimal care, which has led to the emergence of the concept of ‘integrated care’. In 2001, the WHO provided a broad and very general definition of integrated care: “a concept bringing together the inputs, delivery, management, and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion. Integration is a means to improve services in terms of access, quality, satisfaction, and efficiency”.2 In fact, there are numerous descriptions of the notion of integrated care, as evidenced by a 2009 literature review that identified some 175 definitions, highlighting the lack of consensus on the exact meaning of integrated care and/or its inherent polysemic nature.3 Thus, the notion of integrated care is closely related to that of ‘coordinated care’,4 ‘comprehensive care’,5 ‘seamless care’,6 ‘patient-centred medical home’7 or ‘transmural care’,8 though this list is not exhaustive. Integration can occur in two forms: horizontal and vertical. Horizontal integration involves collaboration among providers at the same level of care, such as the centralisation of specialist expertise in regional centres or the merging of primary care centres into a hub-and-spoke model. Vertical integration involves coordination between different levels of care, exemplified by single-site polyclinics that use shared processes and electronic medical records for both primary and secondary care.9
Within this context, dentistry occupies a relatively unique position in the healthcare field. For historical reasons, it is a specialty somewhat separate from medicine, yet it is not considered a paramedical specialty, as dentists have diagnostic and therapeutic autonomy from physicians. Moreover, in most countries, dentistry is taught in faculties distinct from medical schools. This leads to a certain separation in healthcare pathways, between professionals of ‘oral health’ (dentists, hygienists, orthodontists, oral surgeons, etc)10 and those of ‘general health’ (including primary care professionals and medical specialists).
Despite its distinctiveness, dentistry plays a crucial role in the overall healthcare landscape by addressing ‘oral health’, which is obviously integral to ‘general health’ and ‘well-being’. The constructed separation between ‘oral health professions’ and ‘medical professions’ underscores the importance of interdisciplinary collaboration between them. This collaboration is increasingly being recognised as essential for achieving integrated healthcare delivery, where comprehensive services meet the diverse needs of patients across medical and dental domains.
However, the independent position of dentistry within the healthcare field further complicates for dental professionals the already ambiguous medical concept of integrated care. Indeed, integrated care in the dental domain is presented differently across various sources. For instance, some define it as “integrating dental services into an interdisciplinary program of healthcare”,11 while others refer to “integrating oral health into primary care”.12 Additionally, some definitions of integrated care in dentistry focus on ‘incorporating a dentist within an institution’, such as a nursing home, where the dentist examines all residents upon entry and creates a treatment plan.13 These definitions each represent different aspects of what can be considered dental service integration. It is recognised that contemporary dental professionals must practise in a more integrated manner, both individually and collectively.14 However, there is currently a lack of a comprehensive taxonomy that allows policymakers, healthcare system organisers, researchers, professionals and patients themselves to optimise organisations by considering the full spectrum of possible integration of dental services within the overall health landscape.
Our present research aims to establish the foundation for a taxonomy of dental services that is fully integrated into the health domain while minimising historical, cultural or epistemological biases in the organisation of dental services integration. To achieve this, we will adopt a scoping review methodology, guided by theoretical frameworks that view health through a biopsychosocial continuum.14 15 Our work will focus on micro- and meso-systemic levels.16
Aim and objectives
Aim
The aim of this scoping review is to establish a comprehensive taxonomy of ‘dental services’ that can be fully integrated within the broader panorama of health and societal domains, through interprofessional collaborations and systemic organisations.
Our definition of ‘dental services’ is comprehensive, including any activity aimed at preserving or rehabilitating oral functions (see 'Taxon definition'). It also includes activities beyond the oral cavity that oral health professionals could or should provide as part of their healthcare duties.
Objectives
The research objectives presented in this protocol serve as a guide, but they are not exhaustive and additional objectives may emerge during data analysis. To date, the scoping review is expected to meet the following goals:
To identify and analyse various settings and contexts in which ‘dental services’ take place.
To identify and determine the key stakeholders involved in the provision and integration of ‘dental services’.
To explore how dentists are integrated in medical or community settings, particularly in terms of managing non-dental diseases and social aspects.
To examine the existing approaches for integrated ‘dental services’ pathways.
To assess which aspects of ‘dental services’ are most commonly integrated and which remain largely under-addressed.
Methods and analysis
This article outlines the protocol for a scoping review that is currently under development. Although some preliminary data extraction has taken place as part of piloting and methodological refinement, the main phase of analysis is scheduled to begin in April 2025. The planned completion of the review is June 2025.
Scoping review design
This scoping review will adhere to the framework outlined by the Joanna Briggs Institute (JBI),17 which expands on the earlier guidelines established by Arksey and O’Malley18 and Levac et al.19 The review process will be structured into nine distinct stages:
Defining and aligning the review objectives and questions.
Developing and aligning the inclusion criteria with the objective and questions.
Describing the planned approach to evidence searching, selection, extraction and charting.
Searching for the evidence.
Selecting the evidence.
Extracting the evidence.
Charting the evidence.
Summarising the evidence in relation to the objectives and questions.
Consultation. As per JBI guidance, consultation will be built into the review from the outset, by involving a knowledge user (AA) across all stages of the scoping review—see ‘Patient and public involvement in research’.
Complementary, the review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines20 (PRISMA-ScR checklist in online supplemental file).
Supplemental material
Review registration
This protocol has been registered on Open Science Framework (https://osf.io/h37bw/).21
Review team
The review will be conducted by a team comprising expert clinicians and academics specialising in dentistry (BG, KG), a systematic review methodologist (JNV) and a PhD student in epidemiology who also holds a dental degree (vs).
Patient and public involvement in research
The team also includes a patient representative (Association La Dent Bleue), advocate and transdisciplinary researcher (AA) who has been involved from the inception. La Dent Bleue is approved by the French Ministry of Health (Ministerial decree of May 14, 2024; NOR#: TSSZ2413306A). AA has contributed to shaping the aims and objectives of the review and will ensure that patient and family concerns are prioritised throughout the review process.
Taxon definition
In this study, we define a taxon as a construct that we will be seeking in the abstracts/articles obtained from our search strategy. To produce a taxon, the reference must:
mention an activity related to the preservation or the rehabilitation of an ‘oral function’ (see ‘Theoretical frameworks’), in a context of care integration. For example, treatment of caries diseases can be interpreted as the preservation of masticatory and/or social functions, and dental caries prevention by a dentist in a medical setting can generate a taxon that could be denominated ‘Provision of dental services in medical settings’.22
OR
mention an activity not directly related to the preservation or the rehabilitation of an ‘oral function’ but provided by an oral health professional. For example, diabetes screening by a dentist could be denominated ‘Provision of medical services in dental settings’.23
Each new taxon will be validated by consensus within the review team.
Eligibility criteria
The eligibility criteria applied in this scoping review differ across the two phases of the search strategy:
During Phase 1 (top-down approach), we apply broad inclusion criteria focused on identifying the widest possible range of conceptualisations and instances of dental service integration, based on English-language articles indexed in PubMed.
In Phase 2 (bottom-up approach), eligibility criteria will be guided by the preliminary taxonomy built in Phase 1. At this stage, we will seek to fill identified gaps and refine existing categories. This will involve including studies published in other languages and sourced from additional databases and grey literature.
The inclusion and exclusion criteria below apply primarily to Phase 1 but will be adapted flexibly during Phase 2, in line with the iterative nature of the review.
Inclusion criteria
In Phase 1, we will include any type of article (original research, commentary, editorial, etc) indexed in PubMed, published in English between January 2014 and September 2024. The rationale for restricting our search strategy to the PubMed database and to this ten-year time frame is based on three complementary hypotheses: (1) any significant advance in the field of dental services integration is likely to be reported in journals indexed in PubMed; (2) the last decade provides a solid and up-to-date analytical framework that reflects current developments in the organisation of care, while maintaining a manageable scope; and (3) this initial restriction allows us to identify conceptual and systemic gaps more clearly, based on our theoretical frameworks, and to design the second phase of the review accordingly. Articles do not necessarily need to report results regarding the impact of the ‘dental services’ they describe. Articles must allow for the denomination of at least one new taxon, according to the conceptual framework described in this protocol. Studies do not need to report outcomes or effectiveness data to be included.
In Phase 2, the inclusion criteria will be guided by the gaps identified in the preliminary taxonomy established during Phase 1. We will systematically search Embase, CINAHL and Scopus to identify additional relevant studies. This phase will also include exploration of grey literature and non-English publications, particularly when they provide meaningful additions to the taxonomy. No date restriction will be applied in this phase.
Exclusion criteria
In both phases, references that do not permit the denomination of a new taxon—ie, that do not describe an activity relevant to the integration of dental services—will be excluded.
We will also exclude studies focusing exclusively on the macro-systemic level of healthcare systems (eg, national policies, financing models or high-level reforms) without direct implications at the micro- or meso-levels of service delivery.
In Phase 1 specifically, we will exclude non-English articles and studies published before 2014, unless identified later as highly relevant during Phase 2. In Phase 2, these exclusions may be reconsidered in order to enrich and validate the taxonomy.
Screening process
References will be exported to the web-based software Rayyan,24 in order to facilitate the systematic review process and the collaboration within the review team.
We will implement a two-phase dynamic screening process for constructing the taxonomy, consisting of an initial search strategy, completed by an in-depth search strategy.
Phase 1: initial search strategy (top-down)
Based on our theoretical frameworks, we developed an initial search strategy to initiate our literature search, analysis and interpretation. We created a Boolean search strategy specifically for PubMed, which was validated by a medical librarian (DL). This strategy will involve cross-referencing the first two categories with the third (see table 1):
The ‘Medical field (through integrated care)’ category will facilitate the search for articles related to the broad theme of integrated care.
The ‘Social field’ category is derived from the Montreal–Toulouse Model.9 This biopsychosocial model for dentistry includes patient-centredness and social dentistry. It promotes reflective practices among individual oral health professionals for upstream actions at the meso- and macro-levels.
The ‘Dental field’ category includes various aspects of dental care and services provided by dental or non-dental professionals, both within and outside traditional dental settings.
Details of the initial search strategy
The search equation ((social field AND dental field) OR (integrated care AND dental field)) will be employed to initiate the identification and retrieval of taxa. This initial search strategy will be refined through an iterative process of searching, screening and data extraction.
Articles published between January 2014 and September 2024 will be included. The rationale for setting the initial search strategy to start from 2014 is based on our belief that screening the last ten years will provide a solid analytical framework. Then this framework will serve as a foundation for more detailed and in-depth research, guided by the initial results obtained. The iterative nature of the research process may lead to the inclusion of earlier studies when relevant.
Abstracts will be screened by a member of the review team (vs). She will assess each abstract of the initial search strategy, based on the predefined inclusion and exclusion criteria, and will denominate new taxa progressively during the screening process. If the title and/or abstract of a reference does not allow for the production of a new taxon but indicates a potential interest in discovering a new taxon in the full article, the full article will be retrieved, read and analysed to determine if the designation of one or more new taxa from this article is necessary. To ensure rigour, we have planned a validation step where other members of the research team will independently assess a subset of abstracts. Additionally, any ambiguous cases will be discussed collectively and resolved through consensus.
A major update of the search strategy is planned between Phase 1 and Phase 2, based on the preliminary taxonomy established during the initial screening. At this stage, the research team will collectively develop new search equations tailored to explore underrepresented or missing categories of dental services.
Phase 2: iterative refinement and targeted search (bottom-up)
In the second phase, we will develop a new search strategy based on the results obtained from the initial search. During Phase 2, minor iterative refinements may also be made to the search strategy (eg, adding keywords or adjusting filters), depending on the emergence of new patterns. All modifications will be documented and validated by consensus within the review team.
We will explore deeper into certain categories or subcategories of taxa, gathering the review team members to validate the new strategy by consensus. During this phase (bottom-up approach), we will revisit this taxonomy to identify gaps or underrepresented service categories. These gaps will guide a new targeted search in multiple databases, including Embase, CINAHL, Scopus and grey literature sources, without date or language restriction. This process will be repeated until taxon saturation is achieved and updated prior to submission to capture the latest literature. At this point, the taxonomy will be considered finalised, requiring the consensus of the review team.
Taxonomy building
Taxonomy building will require interpreting and classifying taxa within the scope of our frameworks (see ‘Theoretical frameworks’). The taxonomy will be developed iteratively, achieving consensus among the entire review team. Retro-adjustments to the nomenclature of the taxa may be made as they are developed to ensure the final taxonomy is as clear and functional as possible.
We will develop the taxonomy by organising taxa into categories and subcategories, with the branching levels to be determined progressively during the analysis. Through this iterative and inductive process, we will be able to label categories and subcategories that reflect key themes and patterns of dental services integration.
We will prioritise the development of a functional taxonomy over a quantitative evaluation of the number of articles addressing each taxon. Indeed, preliminary pilot research indicates a significant overlap and simultaneity of different taxa within certain individual abstracts/articles. Moreover, the number of indexed references addressing each taxon does not necessarily reflect the real-world deployment of the respective dental service. Ultimately, we aim to avoid fixing the denomination of taxa during the process. To maintain this flexibility, we will not quantify the number of references corresponding to each taxon.
Theoretical frameworks
This scoping review is grounded by theoretical frameworks, which are essential to mention as they guide the entire research process. Indeed, the choice of theory shapes the way researchers collect and interpret evidence.25 We have identified four embedded levels of theoretical framing that are largely compatible with each other. It should facilitate the development of a functional taxonomy that meets our research objectives:
Social construction theory, social complexity and complexity theory
We will anchor our research work from a constructionist perspective. Research conducted within a social construction framework considers the expectations, values, backgrounds and roles of the primary groups involved. It also examines the organisation of the clinic or ward; the allocation of time, space and funding; and the professional and political influences that shape how pain or expectations are expressed, perceived and reinterpreted.25
As Eriksen wrote, “the various characteristics of complex human dynamics also appear as relevant to our understanding the social and psychological importance of the mouth in addition to its biological characteristics”.26 Therefore, we also orient our approach towards the dynamic principles of social complexity. This orientation draws partly from Maturana and Varela’s work on the biological foundations of human understanding27 and partly from complexity theory as applied to social contexts, as articulated by Morin.28
Biopsychosocial model
We will adopt a biopsychosocial perspective of health, based on Engel’s model.15 This perspective will enable us to consider both the biological and psychosocial dimensions of health when examining the integration of ‘dental services’.
Systemic organisations
Valentijn et al identified key dimensions based on the Rainbow Model of Integrated Care and established a taxonomy including micro-, meso- and macro-levels of systemic organisations. This taxonomy helps clarify the different levels of integration and formulate strategies to improve coordination and continuity of care.29 30 In particular, it will allow for the consideration of potential actions by non-oral health professionals in the provision of dental services.
For the dental component of our systemic organisation framework, we will also refer to the Montreal–Toulouse biopsychosocial model in dentistry,14 derived from Bronfenbrenner,16 social dentistry perspectives31 and person-centred care in dentistry.32–35 It will be particularly relevant to consider potential upstream actions by oral health professionals, as described by Bedos et al.14 These upstream actions will be highly significant in a taxonomy of integrated dental care.
Oral functions in a social complexity perspective26
Concerning the framework of ‘dental services’, we will refer more to the functions of the oral cavity rather than its specific diseases. Thus, we will not focus our search strategy on particular diseases, as any oral disease can affect, to varying degrees, one of the functions described by Eriksen in 2003: myo-functional activities (eating, chewing, biting, drinking, smoking, swallowing, sucking, licking, drooling and breathing), sensory functions (taste, mechanical (touch) sensation, temperature and pain), social functions (speaking, singing, playing wind instruments, laughing and mimicry including smile, anger, affection, disappointment and stress), sexuality (kissing and oral sex) and individual identity (aesthetics, social status, cosmetics and body art including oral piercing and jewellery).26
While these theoretical frameworks originate from distinct traditions (biomedical, sociological, systemic), they are not used independently in our review. On the contrary, they are intentionally combined to form a composite and integrative theoretical foundation. These frameworks share numerous conceptual bridges, enabling us to situate dental services not only within the field of medicine but also within broader conceptions of health, well-being and social care. This pluralistic yet coherent approach supports our effort to interpret and classify emerging taxa in a way that is both grounded and open to complexity.
Synthesis of results
During the construction of the taxonomy, we will maintain the link between each taxon and the reference that contributed to its generation. This information will be catalogued in a supplementary results file. For the sake of clarity, we will seek, if necessary and subsequently, an article that provides a more concise and comprehensive description of the taxon. We will report the most evocative references for the identified taxa in a summary table.
We will also produce a data visualisation graph to represent the taxonomy in a visual format.
We will address our five research questions narratively, synthesising the development pathways towards better integration of ‘dental services’.
Critical appraisal of individual sources of evidence
As a scoping review, the aim is to outline the existing evidence and summarise key findings across various domains, rather than assessing the quality of individual studies or determining the risk of bias associated with specific outcomes. Thus, since our goal is to construct a taxonomy, we do not need to evaluate the quality of the studies used to establish it.
Ethics and dissemination
This scoping review analyses published secondary data and does not require ethical review.36 The findings of this study will be disseminated through various channels, including publication in a scientific journal, presentation at conferences and sharing through professional networks.
Perspectives
This scoping review is intended to support healthcare professionals, policymakers and patient representatives by offering a structured and theory-informed taxonomy of integrated dental services. By identifying and naming various forms of integration, this work aims to enhance coordination, accessibility and continuity of care across dental and medical domains. The taxonomy is also expected to inform future research, guide professional training and promote more inclusive and system-oriented approaches to oral services delivery.
Ethics statements
Patient consent for publication
Acknowledgments
The authors are grateful to Pr Christophe Bedos and Pr Paul Monsarrat for constructive discussions and to Denis Laurent, in charge of the odontology library at University Claude Bernard Lyon 1, for reviewing the earlier version of search strategy.
References
Footnotes
X @JnVergnes
Contributors VS, KG, BG and JNV discussed and refined ideas regarding protocol and search strategy. AA provided inputs concerning aims and objectives from patient perspective. VS prepared the first draft. KG, BG, AA and JNV revised the manuscript. VS is the guarantor and accepts full responsibility for the overall content, has access to all relevant information and made the final decision to submit the article for publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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