BACKGROUND: Traditional annual dental quality measures fail to capture real-time care delivery and can mask critical gaps in patient-specific treatment. The authors developed and implemented visit-level adaptations of established caries quality measures to enable actionable, point-of-care assessment. METHODS: The authors conducted a retrospective analysis of 1.09 million dental visits across 400,000 patients (2021-2023) at 4 US institutions using axiUm (Henry Schein Corp) or Epic (Epic Systems) electronic health records. The authors transformed 2 annual measures involving caries risk assessment and risk-based preventive treatment into visit-level metrics using a 2 × 2 matrix framework: action due and performed, due and not performed, not due and performed, not due and not performed. Risk-stratified recall visit intervals determined when actions were due. RESULTS: Visit-level performance consistently underperformed annual metrics. Annual caries risk assessment completion ranged from 60% through 99% across sites; however, visit-level adherence when actions were due dropped, ranging from 41% through 72%. Results of preventive treatment showed greater disparities; only from 28% through 35% of indicated treatments were delivered when due, and from 7% through 32% of visits included treatment when not indicated. Sites with the highest annual performance paradoxically had the most overtreatment. CONCLUSIONS: Visit-level quality measurement exposes substantial undertreatment and inappropriate overtreatment invisible in annual reporting. This granular approach revealed that high-performing institutions according to traditional metrics may be delivering unnecessary care and missing critical prevention opportunities. These findings provide an empirical case study of how misaligned incentives and flawed metrics could systematically drive misuse of resources. Implementation of real-time, visit-based quality measures in clinical workflows could fundamentally transform electronic health records from documentation tools into active instruments for delivering appropriate, value-based, person-centered care. PRACTICAL IMPLICATIONS: Oral health care systems should consider visit-level quality measurement as a means to provide actionable, real-time feedback that can improve clinical decision making at the point of care and prevent waste associated with volume-based care.