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Original Research
Comparison of a Smartphone-Based Photographic Method
with Face-to-Face Caries Assessment: A Mobile Teledentistry Model
Mohamed Estai, MBBS, MSc,
1
Yogesan Kanagasingam, PhD,
2
Boyen Huang, PhD,
3
Julia Shiikha, PhD,
1
Estie Kruger, PhD,
1
Stuart Bunt, DPhil,
1
and Marc Tennant, PhD
1
1
International Research Collaborative–Oral Health and Equity:
School of Anatomy, Physiology and Human Biology, University
of Western Australia, Perth, Australia.
2
Australian e-Health Research Centre, CSIRO, Perth, Australia.
3
School of Dentistry and Health Sciences, Charles Sturt University,
Orange, Australia.
Abstract
Objectives: This study sought to evaluate the efficacy of a
mobile teledentistry approach using a smartphone camera for
remote screening of dental caries. Materials and Methods: An
image acquisition Android App was created to facilitate the
acquisition and transmission of dental images to a store-and-
forward based telemedicine server. One hundred participants
who were attending routine checkups at dental clinics were
enrolled in 2014. Following a face-to-face oral screening by a
screener (dentist), images of patients’ teeth were obtained using
a smartphone camera. These images, along with patient in-
formation, were then transmitted from the Android App to the
server through the Internet for later independent assessment by
two charters (off-site dentists). The assessments of these
charters were then compared to the benchmark face-to-face
caries assessment. Results: Sensitivity values for the photo-
graphic method when compared to the benchmark face-to-face
caries assessment were moderate, and ranged from 60% to
63%. Weighted kappa (K) as a measure of intragrader agree-
ment for the photographic assessment was estimated as almost
perfect (K=0.84). The intergrader agreement for the photo-
graphic method compared to the face-to-face caries assessment
ranged from moderate to substantial (K=0.54–0.66). Con-
clusions: Despite some limitations, the mobile teledentistry
approach has shown the potential to detect occlusal caries from
photographs taken by a smartphone camera with an acceptable
diagnostic performance compared to traditional face-to-face
screening. This study suggests that telemedicine and cellular
phone technology can be combined to create an inexpensive and
reliable screening tool.
Keywords: caries, dental photography, dental screening,
smartphone, teledentistry
Introduction
Caries (tooth decay) is the second most costly diet-
related chronic disease in Australia, ahead of coronary
artery disease and diabetes mellitus.
1
Rural or remote
populations often have poorer oral health than other
groups, primarily due to geographical remoteness and the un-
even distribution of the dental workforce.
2
Caries is often not a
self-limiting disease, but its impact can be prevented or reduced
through regular dental screening, access to fluoridated water,
and oral health promotion.
3
A shift from a ‘‘treatment’’ to
‘‘prevention’’ is the key to reducing or preventing dental caries
among a population. Reaching rural/remote populations to
assess their oral health status is challenging, as this necessitates
lengthy travel, time, and funding. Although unaided face-to-
face screening has remained the gold standard approach to
routine oral examination, this method is inappropriate in large
epidemiological surveys as it requires substantial economic and
human resources. Searching for an inexpensive and valid al-
ternative that can expedite diagnosis of oral diseases among
rural populations, while maintaining a good level of diagnostic
accuracy, is essential.
One of the potentially viable solutions to address geograph-
ical hurdles and the unavailability of dentists, is mobile tele-
dentistry.
4
Mobile teledentistry is a subset of telemedicine that
incorporates cellular phone technology and store-and-forward
telemedicine into oral care services. Almost all smartphones
have a built-in camera and mobile connectivity and are readily
accessible at a low cost. These technologies can be combined to
create an effective teledentistry screening alternative. Despite
dental photography becoming an integral part of daily dental
practice, it has rarely been used as means of diagnosis, consul-
tation, or referral in routine practice. Recent evidence indicates
that the diagnostic performance of photographic methods inthe
detection of oral diseases is comparable to the traditional visual
approach.
5–9
A flash-equipped digital single-lens reflex (DSLR)
camera can produce high-quality images even in a low illumi-
nation setting. However, its relatively high cost, large size
DOI: 10.1089/tmj.2016.0122 ªMARY ANN LIEBERT, INC. VOL. 23 NO. 5 MAY 2017 TELEMEDICINE and e-HEALTH 1
weight, and complexity makes it difficult to use.
10
In contrast,
camera-equipped smartphones are readily available, affordable,
portable, easy to handle, and can produce good-quality im-
ages.
10
The power of cellular technology enables their usage in
various tasks such as processing, storing, and subsequent
sharing of images. Their introduction into other health disci-
plines, in particular, tele-audiology and teledermatology, has
been shown to be beneficial.
11–14
A number of teledentistry studies have been conducted using
DSLR or intraoral cameras to evaluate the accuracy and reli-
ability of photographic methods in oral screening,
5–9
However,
evidence on the use of smartphone cameras in epidemiological
dental research is rare.
4,15
As an initial phase, a validation study
was completed to establish and test a robust store-and-forward
teledentistry system and smartphone app for use in remote
dental screening.
16
In view of the limitations of a face-to-face
screening approach and toward finding a valid and inexpensive
screening solution, the purpose of this study was to evaluate the
efficacy of a mobile teledentistry approach in remote screening
for dental caries.
Materials and Methods
STUDY SAMPLE
Adults or parents/guardians of children visiting the dental
clinic were invited to participate in dental screening, including
obtaining photographs from their mouth. Information sheets and
consent forms were provided to participants. This trial is an ob-
servational cross-sectional study carried out in a dental clinic in
2014, where a sample of one hundred (n=100) participants was
recruited. The inclusion criteria for the participation were patients
of any age, attending a routine checkup, and providing informed
consent. All captured photographs were anonymous and only
showed the participant’s dentition. The research was completed
under ethics approval from the Human Research Ethics Commit-
tee, the University of Western Australia (Ref No.: RA/4/1/6647).
ARCHITECTURE OF THE MOBILE TELEDENTISTRY SYSTEM
A store-and-forward telemedicine server, ‘‘Remote-i,’’ was
developed to facilitate the storage, retrieval, and management
of the database.
16,17
The Remote-i allows the transmission and
storage of photographs online, from either a smartphone or
computer through the Internet. Users can access the database
from any mobile/desktop Web browser using individual user
IDs and passwords. An image acquisition Android app was
also created to operate the existing default camera on a Mo-
torola
MotoG smartphone. The new Android app enabled
patient information to be entered, dental photographs to be
captured, and then allowed subsequent transmission of these
records to the server, using Wi-Fi or mobile data networks.
16
SCREENING (VISUAL AND PHOTOGRAPHIC) PROCEDURES
Using the screening protocol used in our previous trial,
4,16
the unaided face-to-face oral screenings (without radiography)
of all the participants were carried out by a registered dentist to
screen for caries visually. This assessment was used as the
benchmark standard. The face-to-face assessment scores were
recorded on anoral screening form that followed the guidelines
for oral health surveys developed by the World Health Orga-
nization (WHO),
18
a treatment plan or referral was provided
when necessary. In a separate subsequent visit, a trained tele-
dental assistant (dental student or dental assistant) took pho-
tographs of each participant’s mouth using a smartphone
camera (Fig. 1). The teledental assistants were provided with a
photography protocol and received hands-on training on how
to capture good images. They also had the opportunity to
practice using a smartphone camera on volunteers. Only the
room lighting and built-in flash of the smartphone camera were
used during the photography. Neither cheek retractors nor in-
traoral mirrors were used for the dental photography. A mini-
mum of five dental images per patient were taken, front, right
lateral, left lateral, upper occlusal, and lower occlusal views
(Fig. 2). Following the completion of photography and creating
a record on the Android app, each participant’s set of data was
then directly transmitted from the Android app to the Remote-i
server through the Internet, for later evaluation by an off-site
dentist (charter).
OUTCOME ASSESSMENT
The charting of the photographs was conducted indepen-
dently by two dentists (charters) using a separate image-viewing
app built upon the Remote-i system. Dental photographs were
charted without any knowledge of the results of the benchmark
standard. Both charters received instructions about how to use
Fig. 1. Illustration showing the relationship between a smartphone
camera and the mouth during the dental photography.
ESTAI ET AL.
2 TELEMEDICINE and e-HEALTH MAY 2017 ªMARY ANN LIEBERT, INC.
the database, review photographs, insert findings, and submit
their reports into the system. Charters accessed the database
using user IDs and passwords. After selecting a record, each
charter reviewed images and commented on the dentition status
for each tooth on a predefined assessment chart. The external
reviewers (screeners/charter) also had access to other personal
information about the participants such as date of birth, gender,
and postcode, as well as Indigenous status. These independent
assessments by charters formulated the database, which was
compared to the benchmark face-to-face caries assessments.
Caries assessment was completed at tooth level based on a
protocol developed by the WHO.
18
This protocol has the ad-
vantage that it has been designed to be simple and easy to use
in large-scale oral health surveys. At the screening level, the
use of the International Caries
Detection and Assessment System
(ICDAS) method was not possible
because intraoral photographs
only provide a two-dimensional
view, which makes it difficult to
carry out the analysis based on the
tooth surface.
STATISTICAL ANALYSIS
Weighted kappa (K) statistic was
used to estimate the intergrader
reliability of the photographic and
face-to-face caries assessment
methods.
19
To estimate the in-
tragrader agreement, 15% of the
records were recharted again, at
least 4 weeks after the initial
charting of the dental photo-
graphs. The sensitivity, specific-
ity, accuracy, positive-predictive
value, and negative-predictive
value of the photographic method
for each charter were calculated.
Because photographs only provide
a two-dimensional view, it is dif-
ficult to inspect all surfaces of the
teeth, particularly the interproxi-
mal surfaces of posterior teeth.
Therefore, the assessment of caries
was based on the entire tooth ra-
ther than tooth surface, with the
teeth scored as either having caries
or being sound. Interproximal or
root caries were excluded, due the
difficulty of detecting these carious lesions in photographs. Filled
and missing teeth were also excluded from the analysis. The
sample size calculation was based on a two-sided 95% CI
(confidence interval) for a single proportion using the Z-test
approximation, an effect size of 0.1 and an expected observed
proportion of 0.90. The number of participants with caries that
met a power of 0.8 was estimated to be 35 [n‡(Z
2
/m
2
)·
p(1-p)].
20
With the prevalence of caries at 35% (1.86 ·35 =
65), 65 participants without caries are needed. So a sample of
100 participants was recruited.
Results
The demographic characteristics of the sample are pre-
sented in Table 1. Approximately, 500 dental photographs
Fig. 2. Examples of smartphone camera shots showing five dental views. (a) Front view; (b) upper
occlusal view; (c) lower occlusal view; (d) left lateral view; and (e) right lateral view.
SMARTPHONE-BASED PHOTOGRAPHIC ASSESSMENT OF CARIES
ªMARY ANN LIEBERT, INC. VOL. 23 NO. 5 MAY 2017 TELEMEDICINE and e-HEALTH 3
(5 photographs per subject) were obtained from the participants
using the smartphone’s camera. Of 3,200 teeth scored, the
percentage of unrated (not amenable to be scored) teeth was 8%
(266 teeth) for charter 1 and 19% (596 teeth) for charter 2.
Sensitivity and specificity values for the photographic method
compared to the benchmark face-to-face caries assessment
ranged from 60% to 63% and from 96% to 99%, respectively.
The sensitivity value for the photographic caries assessment
(charter 1 vs. charter 2) was 85%. Weighted kappa as a measure
of intragrader agreement for the photographic assessments was
almost perfect (K=0.84). The intergrader agreement between
the two methods of screening (photographic vs. face-to-face)
ranged from moderate to substantial (K=0.54–0.66). The level
of intergrader agreement between charter 1 and charter 2 was
substantial (K=0.68). The diagnostic accuracy measures and
level of agreements for both photographic and face-to-face
screening methods are presented in Table 2.
Discussion
This study shows that the combination of store-and-
forward telemedicine and inexpensive smartphone camera
use, offers a valid and reliable means of remote screening for
dental caries. Despite the scarcity of research evidence on the
use of a smartphone camera in dental screening, the present
findings strengthened our previous reports that the mobile
teledentistry approach has the potential to detect caries from
a photograph taken by a smartphone camera with an ac-
ceptable ‘‘moderate’’ diagnostic validity and reliability.
4,16
It
is acknowledged that neither the photographic method nor a
standard face-to-face screening approach can detect inter-
proximal or precavitated carious lesions without radiogra-
phy examination and the failure to use radiography could
result in underestimation of caries occurrence. Therefore, at
the screening level, the focus of this study was on the
evaluation of efficacy of a mobile teledentistry approach for
dental screening, not for the clinical estimation of caries
prevalence.
Our findings showed a moderate level of concordance be-
tween the two screening approaches (photographic vs. face-
to-face) and the two dentist charters. It is well-known that
different dentists can reach different diagnostic outcomes.
21
The moderate level of concordance (K=0.68) between the
two charters was most likely due to the difference in clinical
experience and training. Although both charters had a lower
level of intergrader agreement relative to the benchmark
face-to-face screening, the intragrader agreement for the
photographic assessment was quite high, suggesting that the
charters were uniform in the charting and the way they de-
tected caries from the photographs.
Despite ‘‘unaided’’ face-to-face oral examination being the
primarymethodusedtoassessoralhealthstatus,previousre-
search has shown that this technique is not accurate, with a
sensitivity of less than 50%.
22,23
Our results indicate that pho-
tographic caries assessment maintained a relatively moderate
level of sensitivity and a very high specificity, comparable to that
of face-to-face caries assessment. The specificity values were
higher than sensitivity values across the two charters and the two
screening approaches. The higher value for the specificity could
be attributed to the inability of the charters to see some carious
lesions on a photograph compared to the benchmark face-to-
face assessment. The sensitivity of the photographic method
(charter 1 vs. charter 2) met the WHO’s reference standard
of 0.85–0.90.
18
In contrast, the sensitivity scores for the
Table 1. Demographic Characteristics of the Sample
NUMBER
Total 100
Female 36
Male 64
Aboriginal and Torres Strait Islander 20
Non-Indigenous 80
0–14 years 20
15–24 years 23
25–44 years 22
45–64 years 22
65+years 13
Table 2. Accuracy and Reliability Measures
BENCHMARK
SCREENING
VERSUS
CHARTER 1
BENCHMARK
SCREENING
VERSUS
CHARTER 2
CHARTER 1
VERSUS
CHARTER 2
Sensitivity (%) 63 60 85
Specificity (%) 99 96 97
Accuracy (%) 97 94 96
PPV (%) 79 52 58
NPV (%) 98 97 99
Kappa statistic (95% CI) 0.66 (0.59–0.75) 0.54 (0.41–0.63) 0.68 (0.56–0.77)
Benchmark screening: face-to-face oral screening; Charter: photographic
caries assessment.
CI, confidence interval; NPV, negative-predictive value; PPV, positive-predictive value.
ESTAI ET AL.
4 TELEMEDICINE and e-HEALTH MAY 2017 ªMARY ANN LIEBERT, INC.
photographic method (60–63%) compared to the benchmark
face-to-face assessment were lower than the WHO’s reference
standard. The lower value of the sensitivity is likely to be because
filled and missing teeth were not included in the analysis.
Missing teeth and restorations/fillings are more likely to be de-
tected on a photograph.
16
Charter 1 had a slightly higher level of
concordance and sensitivity relative to charter 2. This is probably
explained by the potential of charter 1 to identify carious lesions
on the photographs more than the other charter or when un-
certain by rating a tooth with suspected lesion as having caries.
Our previous research,
24
demonstrated that some photographs
taken by smartphone were of low quality; we attributed this to
a failure to comply with the photography protocol or due to the
presence of saliva, blood, or debris. For the purpose of facilitating
thechartingprocess,bothcharterswereaskedtoscoreanytooth
not amenable to be scored as ‘‘unrated.’’ The difficulty in de-
tecting carious lesions on the photographs and distinguishing
them from artifacts could justify why charters scored some teeth
as ‘‘unrated.’’ Such drawbacks could contribute to the suboptimal
sensitivity and specificity. This is consistent with previous re-
search that reported variations in the inter-rater reliability in
caries detection, mainly in the posterior teeth, attributed to fissure
morphology or staining.
25,26
It is well known that assessment of
caries from photographs has a shortcoming in that a photograph
can only provide a two-dimensional view, which prevents ob-
serving all tooth surfaces, particularly the interproximal surfaces
of posterior teeth (molars).
4,24
The photographic method is also
known to have limitations for the detection of caries on root
surfaces (unless they are exposed through gingival recession) or
nonvisible secondary caries. The two-dimensional view allows
detection of carious lesions mostly on the occlusal surfaces,
buccal and lingual surfaces, of the teeth. The teledentistry ap-
proach to dental screening (incomplete oral examination), used
within the framework of its limitation, offers a reliable means of
remote dental screening. This method can be most effective when
a shortened arch with a reduced number of surfaces of limited
visibility is present, such as in children.
From a practical point of view, it seems reasonable to take
advantage of the advances in information and communication
technology and increasingly widespread global connectivity to
utilize potential cost-saving solutions such as smartphone use
to make oral care services more accessible. Until recently, the
use of the smartphone in telemedicine was not well received
because of the low quality of the built-in cameras, limited
storage space, and unsuccessful data transmission.
10
With
many people now possessing smartphones, their use in routine
dental services is projected to increase due to their inherent
digital imaging capabilities, computational power, and sharing
ability as well as access to low-cost, secure cloud storage.
Due to the shortage of dentists practicing in rural com-
munities, residents in these regions may seek dental care
from general medical practitioners (GPs) or emergency de-
partments. This can result in underreferral or unselective
referral of patients who need a specialist consultation, in-
creasing the burden on rural populations through additional
travel and increased waiting times. The mobile teledentistry
approach to dental screen holds great promise for rural or
remote communities where dental care services are limited.
At the screening level, GPs, nurses, or even nonlicenced
health professionals such as teachers or caregivers can ob-
tain digital data (dental photos) for later evaluation by
adentistatadistance.
27,28
A dental expert accessing the
database from the desktop can assess the records and de-
termine whether cases need a referral or can be delayed. This
approach provides a way to identify those for whom referral
is unnecessary or prioritizing those requiring an urgent
assessment by a dental specialist. This has the potential to
reduce inappropriate referrals and prioritize patient assess-
ments, thus avoiding unnecessary travel and reducing
waiting times.
29–31
Conclusion
Despite some limitations, this study suggests that the mo-
bile teledentistry approach has the potential to detect occlusal
caries from photographs taken by a smartphone camera with
an acceptable diagnostic level. To improve the oral health of a
population, ongoing monitoring of oral health status, using
valid and inexpensive screening tools, is necessary. In light of
the limitations of the face-to-face dental screening approach
in large epidemiological studies, it is possible that a mobile
teledentistry approach can offer a potential cost-saving al-
ternative to address the problems of care access and the rising
costs of dental care. Further well-designed research is required
to address the existing limitations and improve the diagnostic
performance of the teledentistry approach.
Acknowledgments
The authors received no financial support for this work. We
would like to acknowledge the kind assistance of Dr. Christo-
pher Pantin, Mrs. Debbie Williams, and Ms. Jennine Bywaters
from Absolute Dental for their efforts in data collection. We
also acknowledge the assistance of Dr. Jacques Filez from the
University ofWestern Australia for his contribution in this trial.
We would like to thank Di Xiao and Janardhan Vignarajan
from CSIRO Australia for their technical support. Thanks also to
dental students (Andrew Liaw, Olivia Haselton, and Abhayjit
Dhillon) at the dental school, James Cook University, for their
efforts in data collection.
SMARTPHONE-BASED PHOTOGRAPHIC ASSESSMENT OF CARIES
ªMARY ANN LIEBERT, INC. VOL. 23 NO. 5 MAY 2017 TELEMEDICINE and e-HEALTH 5
Authors’ Contributions
M.E., the main author contributed toconception, design, data
acquisition, analysis, and interpretation, drafted, and critically
revised the article; M.T., S.B. and E.K., contributed to design,
data analysis, and critically revised the article; Y.K., contributed
to development of the telemedicine system and critically revised
the article; B.H., contributed to data acquisition and critically
revised the article; J.S., contributed to data acquisition and
critically revised the article. All authors gave final approval and
agree to be accountable for all aspects of the work.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Mohamed Estai, MBBS, MSc
International Research Collaborative–
Oral Health and Equity:
School of Anatomy, Physiology and Human Biology
University of Western Australia (M309)
35 Stirling Highway, Crawley
Perth 6009 WA
Australia
E-mail: abdalla177@gmail.com
Received: June 2, 2016
Revised: August 24, 2016
Accepted: August 28, 2016
ESTAI ET AL.
6 TELEMEDICINE and e-HEALTH MAY 2017 ªMARY ANN LIEBERT, INC.
