Tangibility refers to the visual appeal of physical structures, devices, staff, and communication materials (25). Patients anticipate immaculate and aesthetically pleasing facilities. Although the appearance of clinical settings may not be the foremost determinant of service quality, it does significantly influence how patients perceive the quality of service and satisfaction, particularly when the dental office guarantees outstanding service and a superior experience (26). Also, a previous study found that the appearance of dental staff members in terms of cleanliness and neatness was considered the most important item in the tangibility factor (27).

Therefore, in the context of a dental hospital, the physical attributes of the practice, such as its interior design and atmosphere, and the modern technology and advanced equipment used in the dental hospitals, receptions, and waiting rooms, may have a significant positive effect on the patients' intention to revisit the dental hospital. Based on this context, the following hypothesis is proposed.

H1: Tangibility has a significant positive influence on the patients' intention to revisit the UQU-DTH.

Reliability can be defined as the capacity to consistently and precisely provide the committed service (24). Within the dentistry field, this process encompasses all aspects of patients' engagement, including the provision and implementation of necessary services or treatments as promised, as well as the resolution of any issues or concerns that patients have. When patients visit a hospital for dental treatment, they expect the dental practice to be reliable, and the success of a hospital often depends on its ability to satisfy these expectations (28). Prior research has shown inconsistencies in hospitals' capacity to maintain a record free of errors, potentially impacting patients' confidence and contentment in the hospital (20).

Thus, this typically influences the intention of revisiting. This justification leads to the proposition of the following hypothesis:

H2: Reliability has a significant positive influence on the patients' intention to revisit the UQU-DTH.

This factor demonstrated the commitment and capability of dental hospital staff to provide patients with on-time care. Being a responsive healthcare organization means taking in, evaluating, and quickly addressing requests, comments, queries, and concerns from patients (15). High-quality dental hospital services always reply to patient communications as quickly as possible, which is typically a sign of how much importance the hospital places on patient experience (25).

According to earlier research, responsiveness significantly affects the quality of services (23). Certain dental procedures often require multiple visits. The time between patient assessment and treatment sessions was a key element in the responsiveness factor in the dental settings because of the workload on highly specialized clinics. This might have an effect on the patients' intention to revisit the dental hospital. Therefore, the following hypothesis is formulated.

H3: Responsiveness has a significant positive influence on the patients' intention to revisit the UQU-DTH.

Assurance refers to the sense of belief and confidence that patients have in a certain healthcare institution (15). Within the context of dentistry, it is crucial to establish trust in the dental care providers and the organization they're employed for, particularly when it comes to complex dental management that patients may find difficult to comprehend and assess. This trust is essential for ensuring that patients receive the necessary treatment with confidence.

Several studies have shown that the assurance factor was considered the most crucial factor, consistently receiving the highest values when compared to other factors (15, 29). This has a propensity to impact the patients' intention to revisit the dental hospital. Based on this context, the following hypothesis is proposed.

H4: Assurance has a significant positive influence on the patients' intention to revisit the dental hospital.

Empathy relates to the manner in which a dental hospital provides its services, creating an atmosphere in the hospital that seems understanding and responsive to the wishes and expectations of its patients (18). Patients' who perceives a hospital's genuine concern for their welfare is inclined to exhibit more loyalty and revisit intention towards that dental hospital (16). Furthermore, it elucidates the way in which the organization offers care and individualized attention to its patients. Therefore, the following hypothesis is formulated.

H5: Empathy has a significant positive influence on the patients' intention to revisit the UQU-DTH.

This factor pertains to the patients' perception that the dental services provided by the dental hospital are reasonably priced and offer satisfactory value in relation to the amount of money spent (29). Prior research has shown that the cost of dental treatments was the most significant factor influencing the success of a dental business. Additionally, it was considered a factor that contributed to patient satisfaction (30). The affordability of dental care services plays a crucial role in shaping consumers' choices to use dental clinics and it is essential that the cost of dental care remains reasonable and accessible (23). Also, the availability of affordable healthcare services for patients may serve as a gauge of service quality (14).

Therefore, it may be inferred that if the patients are satisfied with the costs, they are more inclined to revisit and endorse the service to others. Based on this context, the following hypothesis is proposed.

H6: Cost-effectiveness has a significant positive influence on the patients' intention to revisit the UQU-DTH.

This factor pertains to the personality traits and professionalism of the staff, including their expertise, professional abilities, and ability to explain treatment plans clearly to patients. According to a previous study, patients' perceptions of the dentists' skills are crucial, and some patients show low confidence in dental students (30). Also, a previous study showed that patients consider professional expertise and personal characteristics, such as gender, age, and ethnicity, as influential factors when selecting a dentist (31).

Furthermore, another study explained that among the primary determinants that determine patients' attitudes towards dentists are the ethical conduct of the dentist, an accurate diagnosis and high-quality treatment, and the communication proficiency of the dentist (32). Thus, the following hypothesis is formulated.

H7: Staff-related factors has a significant positive influence on the patients' intention to revisit the UQU-DTH.

This factor can be described as the extent to which hospital administrators have formulated strategies, such as delivering high-quality services and creating a positive experience, to encourage specific behaviors in patients with the aim of fostering long-term relationships (14–16). This, in turn, leads to patients returning to the same healthcare provider for their health care requirement. Given the significance of patients' revisit intentions for hospital management in terms of competitiveness, credibility, and revenue (14). In the dental context, revisit intention can be referred to a patient's desire to return to the same dental care facility to receive dental treatment.

The concept of revisit intention encompasses two primary items: the desire or readiness to recommend the hospital to others, and the intention or readiness to return to the hospital. This research has chosen revisit intention as the dependent variable. This leads us to propose the following hypothesis.

H8: Overall, the proposed extended SERVQUAL model significantly predicts patients' behavioral intention to revisit the UQU-DTH.

Authorization to carry out this study was obtained from the Research and Ethics Committee of Umm Al-Qura University Approval No. (HAPO-02-K-012-2023-05-1635).

The cross-sectional study was conducted from September to November 2023 in the outpatient waiting areas and clinical settings of the Umm Al-Qura University Dental Teaching Hospital at (UQU-DTH). The research participants were drawn from the patient population who sought dental care at the hospital. The research included patients who were over 18 years old and accepted the request to participate, as well as those who visited the hospital once or multiple times. The research excluded patients who lacked the ability to read or comprehend the questionnaire and those who were below the age of 18. The method of convenience sampling was used to provide a proximately representative proportion of patients to ensure that the recruited sample will be represented as much as possible. To determine the minimum sample size for the study, the Raosoft online sample calculator was used. With a margin of error of 5%, a confidence interval of 95%, a response distribution of 50%, and a population of approximately 2,000, the recommended sample size was 323 patients. In order to account for missing data or incomplete responses, the sample size was 10% inflated, and 355 patients were invited to participate in the study.

The data for this research was collected using an Arabic version of the SERVQUAL instrument (20). The Arabic questionnaire was used due to the predominant number of patients who are native Arabic speakers. The items related to the additional factors, specifically cost-effectiveness, staff-related factors, and revisit intention, were derived from prior empirical studies (14–16). A committee consisting of four faculty members and educators from the authors' dental school was invited to check the validity of the final version of the questionnaire and thoroughly examine its wording, semantics, phrasing, and experiential aspects. Then, the questionnaire was piloted with a group of 20 patients who were not part of the research. Following the pilot inquiry, some words were modified.

An online platform (http://forms.microsoft.com) was used to distribute the questionnaire to patients who attended the hospital during business hours. The questionnaire contains the following sections: The first section contains a participant information sheet. The second section included consent statements. The third section contains demographic questions, including gender, age, nationality, education level, type of visit, place of residence, and reason for visiting. The fourth section included 32 service-quality items. The responses measured using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).

The distribution of the questionnaire scores was determined using descriptive statistics and frequency analyses (mean and standard deviation). The reliability (internal consistency) of the questionnaire items in each factor was examined using Cronbach's alpha (33). The study used hierarchical regression analysis to investigate the relationship between the independent factors and the dependent factor (revisit intention) while accounting for the impact of demographic variables (34). Variance inflation (VIF) analysis was used to measure multicollinearity; results of less than 10 indicate the absence of multicollinearity. The results imply that there are no problems with multicollinearity. The analysis was conducted using IBM, Inc.'s SPSS Version 29.0.

A total of 330 completed responses were received, with a 93% response rate. The participants were comprised of 61.5% males and 38.5% females. Of these, 63.3% were under the age of 35, and 36.7% were over the age of 35. Forty percent of the participants had a university education, while 24.2% and 35.8% were in primary/secondary and high school level groups, respectively. Of the 330 patients, 59.1% came for multiple visits, while 40.9 came for the first and second time. In addition, 83.9 percent of participants came for dental treatment, while 10.9% and 5.2% came for check-up/consultation and emergency care, respectively. The majority of participants 72.1% were treated by undergraduate dental students. The remaining participants received dental care from dental interns, postgraduate dentists, and faculty members, with 17%, 4.8%, and 6.1%, respectively. Furthermore, 58.5% were non-Saudis, while 41.5 were Saudis.

Cronbach's alpha scores shown in Table 1 indicated that each factor exhibited strong internal reliability. All factors showed excellent alpha (α) scores with a range from 0.796 to 0.922.

The descriptive statistics for each factor are shown in Table 1. All measurements were on a 5-point Likert scale. The means of the responsiveness and tangible factors were ranked as the lowest, with means scores of 4.43 and 4.46, respectively. The mean score of revisit intention was the highest, at 4.63. Also, “staff give prompt service to patients” and “the hospital has visual appeal and comfortable physical facilities” items had the lowest mean scores at 4.21 and 4.27 respectively. The item “Staff treat patient with dignity and respect” had the highest mean scores, at 4.72 (Table 1).

The limitations of this research center on its geographical viability, since it was restricted to a single public dental teaching hospital. As such, it may not accurately reflect the opinions of Saudi patients who have attended privately held dental hospitals. A comprehensive picture might be obtained from future research comparing the quality of care offered by public and private hospitals. Furthermore, it is important to note that the patient's revisit intention may vary as time progresses. Therefore, a cross-sectional design may not be appropriate for effectively monitoring and analyzing these changes. A future longitudinal study may provide a better grasp of the factors investigated. Additionally, using a convenience sample strategy may restrict our capacity to generalize findings to a broader population.

This study showed that the added factors “cost-effectiveness” and “staff-related factors” were useful in predicting patients' revisit intentions. They should be added to the SERVQUAL model when it is used for assessing dental services. The proposed model has never been used in the dental services context and could be utilized to provide a solid theoretical foundation for service quality and employed as a robust theoretical framework for assessing service quality. At the level of the organization, the approach may be used to constantly assess and regulate the quality of services. Additionally, it may be used for the aim of developing hospital services, including the formulation of initial objectives and targets, the execution of operational strategic administration, and future-oriented competitive advertising. Moreover, it assists in identifying the specific areas that need standardization and improvement.

The primary recommendations of this research indicate that staff-related factors have a significant impact on the probability of patients revisiting the hospital. Thus, it is essential for dental institutions to prioritize the recruitment of staff that possess exceptional expertise, vast knowledge, and excellent interpersonal skills for effective patient communication. In dental clinics, since the duration of dental treatment is often longer than in regular medical treatments, effective communication between dentists and patients is crucial. Another crucial recommendation is the need to increase the number of public dental hospitals. The government in Saudi Arabia provides coverage for the majority of dental care at the public dental hospital. Nevertheless, the overwhelming demand placed on the public hospital results in significant delays in accessing dental care. Finally, Moreover, including these criteria in the assessment models, auditing strategies, procedures, and policies of dental hospitals in a uniform manner is expected to enhance patient care processes and improve the overall quality performance of hospitals.