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Comparison of a Smartphone-Based Photographic Method with Face-to-Face Caries Assessment: A Mobile Teledentistry Model

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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 information, 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 photographic 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 agreement for the photographic assessment was estimated as almost perfect (K = 0.84). The intergrader agreement for the photographic method compared to the face-to-face caries assessment ranged from moderate to substantial (K = 0.54-0.66). Conclusions: 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.
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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.
... In the current scenario of COVID-19, Teledentistry has brought numerous advantages (Table I), but nothing can compare to the accuracy of the patient's clinical-in-person diagnosis (Fricton & Chen, 2009;Bradley et al., 2010;Daniel & Kumar, 2014;Estai et al., 2016Estai et al., , 2017. Teledentistry has its advantages and limitations (Table II), which generates a lack of acceptance on the part of dentists, considering it complex, making them resistant to new skills (Fricton & Chen, 2009;Bradley et al., 2010;Daniel & Kumar, 2014;Estai et al., 2016Estai et al., , 2017Meurer, 2020). ...
... In the current scenario of COVID-19, Teledentistry has brought numerous advantages (Table I), but nothing can compare to the accuracy of the patient's clinical-in-person diagnosis (Fricton & Chen, 2009;Bradley et al., 2010;Daniel & Kumar, 2014;Estai et al., 2016Estai et al., , 2017. Teledentistry has its advantages and limitations (Table II), which generates a lack of acceptance on the part of dentists, considering it complex, making them resistant to new skills (Fricton & Chen, 2009;Bradley et al., 2010;Daniel & Kumar, 2014;Estai et al., 2016Estai et al., , 2017Meurer, 2020). ...
... Some professionals believed that this modality of dental care would be "cold" and "distant", however over time it was observed that some patients reported being more satisfied (Bradley et al., 2010;Estai et al., 2016Estai et al., , 2017 After all, it is clear that the absence of physical contact needs to be rewarded by empathic skills in online communication, such as listening, showing attention, ensuring verbal clarity, adequate facial expression, and coherent intonation. Online consultations allow the exchange of different types of data, such as written or voice messages, as well as therapeutic suggestions, video messages for a better assessment of the patient's needs, and descriptions of the problems in their own words. ...
... Mclaren., et al. [38] like the authors [27][28][29][30][31][32][33][34]38,45] tions. The percentage of agreement between both diagnostic methods ranged between 93.33% and 100%, with a Kappa coefficient between good and very good (kappa = 0.7-1). ...
... All the authors mentioned [18,[28][29][30][31][32][33][34]38] agree on several characteristics of teleodontology without differences in its modality. ...
... In the studies included in this section, there was consensus that teleodontology improves access to health services and care with specialists, presenting greater availability and acceptance by patients and their caregivers [18,[28][29][30][31][32][33][34]38]. They agree on the applicability of teleodontology for patients in rural and urban areas with limited access, and even Morosini., ...
... The different modalities of teledentistry are synchronous live videos, asynchronous teledentistry, remote patient monitoring, and mobile health (mHealth) care services [1]. Mobile smartphones are excellent teledentistry tools as they are readily available, user-friendly, and cheap [2]. ...
... Nowadays, dental photography is a standard element of daily practice and plays an important role in dental diagnosis, consultations, and referrals. Teledentistry models using smartphone have shown high acceptability [2]. Few recent studies have shown the considerable reliability of mobile phone photographs in diagnosing dental caries in children. ...
... This system is useful, for instance, for consultation about periodontal treatments or dysgnath surgeries. The third technique is the so-called "remote patient monitoring", which is a mixture of the two previous options, when biometric data are obtained and stored before the session and made accessible during the session, or generated online, during the session with appropriate equipment [34][35][36][37]. These can save time either by shortening of a session, or by replacing a regular face-to-face session with a virtual one. ...
Article
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Background In the twenty-first century, health systems have to cope with the challenges posed by their rapidly changing environment. Among these changes, the emergence of digital health solutions is an opportunity to make health systems better, but also a compelling force to change. Community dentistry is one area of health care, where the rapid technological development has the potential for substantial performance improvement benefitting dental patients in terms of access to care and conveniance. Methods This study is based on a survey of the dental care provided by three units (Oral Medicine, Periodontology, Orthodontics) of the Department of Community Dentistry, Semmelweis University, Budapest. During a period of 12 weeks, we have collected time balance data on 1131 patients, 539 in the traditional and 592 in a pilot teledentistry setting, in order to estimate how much time could be spared by monitoring patients through videoconferencing instead of face-to-face visits. Results According to our findings, teledentistry has the potential to shorten the visit with an average of 5–10 min per patient, which adds up to 58–116 work hours in a year. If the pilot was rolled out to all the 13 chairs of the surveyed 3 specialties (orthodontics, periodontology and oral medicine) the time saving would sum up to 186 workdays in one shift alone, which would translate to close to 4500 additional patients per year, considering remote patient monitoring cases alone. Further, if inactive doctors and highly qualified dental hygienists were involved in delivering telecare, 2.67 times as many workdays could be spared, which would allow about 12,000 more patients treated per year. Conclusions The rapid development of digital health technologies coupled with the evolving task distribution between health professionals have a great potential to improve health system performance in pursuit of population health. Unfortunately, the adaptation to these technological changes is uneven, and without a national strategy, the poor will unlikely benefit from these opportunities in public dental care.
... [26][27][28] Moreover, several mobile applications for improving oral health have been developed to provide knowledge about oral health care as an oral health screening before referring to the dentist and to assess the caries risk of an individual. 24,[29][30][31] However, there is not a widely used mobile application in Thailand for dental CRA that uses a comprehensive evaluation of the related factors. Therefore, to promote access to a dental CRA tool and oral health education focusing on dental caries prevention, the aim of the present study was to develop a CRA tool using mobile health technology based on oral behaviour change for adolescent and young adults who are frequent users of mobile technologies. ...
Article
Objectives: To develop a caries-risk assessment application (myRisk app) and assess the psychometric properties based on content validity, construct validity and how well it classifies the participants into different caries risk groups using caries increments at 10 months. Methods: The myRisk mobile application was developed using Android Studio 4.1.1. The content validity was assessed by three dental experts. To evaluate construct validity and the prediction of future dental caries, the participants (N = 88) were recruited from Rajvithi Home for Girls in Thailand by convenience sampling. The participants were completed caries risk assessment of myRisk app and ADA form. The oral examination was performed at the time of caries risk assessment and 10 months following the baseline. Results: Eighty-eight participants aged 12-29 used the myRisk app and completed the ADA form. The app content validity was acceptable (IOC=0.67). According to myRisk, 7.9 %, 71.6%, and 20.5% of the participants were classified into the low, moderate, and high risk group, respectively. The percent agreement of the caries-risk classification with the ADA form was 30.7%. Significant differences between the three risk groups were found in active caries (p<0.001), type, and frequency of sugary snacks (p=0.002). The app had sensitivity of 68%, specificity of 61% and area under ROC curve of 0.61. Conclusions: The myRisk app has acceptable content validity and sufficient diagnostic accuracy (sensitivity, specificity and ROC curve). However, there is a different outcome in caries-risk classification compared with the ADA form. Trial registration: Thai Clinical Trials Registry (TCTR), TCTR20220819004. Registered 19 August 2022 - Retrospectively registered, https://www.thaiclinicaltrials.org/show/ TCTR20220819004.
... Clinical examination and remote screening of patients, for example through WhatsApp images, can be a suitable, reliable and cost-effective tool in a low-resource environment [22,29,30]. Barriers to teledentistry include patients' lack of knowledge about IT, poor and inadequate IT literacy of dentists, unfamiliarity of dentists and patients with technology, limitations in infrastructure (such as poor internet access, lack of hardware, cost and efficiency of equipment), low video quality, audio-video mismatch that can be replaced by direct communication (simultaneous communication), how to Partner institutions that helped to produce articles related to teledentistry during Covid-19 pandemic found in the WOS database store, send and share patient information, confidentiality and protection of patient information, organizational changes in accepting teledentistry, non-acceptance of teledentistry services by relevant authorities including insurance companies, lack of transparency in reimbursement, non-cooperation of other medical centers, inadequate circulars, cost of installing teledentistry equipment and resistance of dentists to new technologies [3,9,19,20,22,24,25,31]. ...
Article
Full-text available
Introduction During Covid-19 pandemic, people have been reluctant to visit dentist due to the fear of infection. Dentists have also suffered from severe turmoil. Teledentistry has been considered as a key strategy for managing people’s oral health. The aim of this study was to investigate teledentistry services in the world during the Covid-19 pandemic and to learn from different experiences. Materials and methods The Web of Science database was searched by scientometric analysis approach, using keywords such as Covid-19, telemedicine, teledentistry and synonymous keywords derived from MeSH. Consequently, 94 articles were extracted from which, 15 articles related to teledentistry during Covid-19 were included in the study, considering the inclusion and exclusion criteria. Results Scientometric analysis and illustration of retrieved articles were performed to identify authors, organizations and countries, and to review cooperation and collaboration networks in this field. Teledentistry was studied during Covid-19 in countries such as China, United States, Japan, Italy and United Kingdom. Types of the software used for communication between dentists and patients were WeChat, BigWord telephone translator, iGAM, WhatsApp, Attend Anywhere (AA), DeRS. The software used for data storage were Mouthwatch TeleDent, and Proforma. For data processing and decision making decision tree algorithms, automated algorithms were employed. Conclusion Teledentistry has the potential to improve the provision of dental services. A fundamental review and careful planning is required to provide such services, particularly in developing countries. Furthermore teledentistry needs more in-depth studies in order to overcome existing and future obstacles and risks while taking advantage of its benefits.
... Their intraoral photographs showed sensitivity and specificity of 60 and 97, respectively, compared to the clinical visual examination. 40 In comparison, the current study asked teachers (non-dental personnel) to take the photographs, but the examination was carried out by a dentist, yielding sensitivity scores of 98.3 in primary and 88.5 in permanent teeth for the nondental teledentistry examination, and specificity of 91.4 for primary teeth and 96.1 for permanent teeth. This big difference in sensitivity between both studies could be a result of the failure of the dental assistants to accurately detect dental caries in the photographs. ...
Article
Full-text available
Introduction: : The increasing burden of dental caries and the lack of effective dental caries screening protocols in non-dental settings, such as schools, demand an innovative and cost-effective approach. Teledentistry is the field of dentistry that combines telecommunication with health records and digital imaging to improve access to dental care and help in epidemiological surveys. This study aimed to assess the accuracy of non-dentist teledentistry in caries detection compared with the clinical dental examination of a sample of 5-10-year-old schoolchildren. Methods: A calibrated dentist examined schoolchildren aged 5-10 years old. The dentist and two teachers took intraoral photographs for each child, using a smartphone. The photographs were concealed; therefore, the dentist assessed the three sets of photographs blindly two weeks after the clinical examination. Accuracy was measured to compare the teledentistry examination with the clinical dental examination. Results: The mean DMFT of primary teeth was 3.38, 3.42, and 3.17 upon clinical examination, dental-teledentistry examination (findings of photographs taken by a dentist), and non-dental teledentistry (findings of photographs taken by teachers), respectively. The mean DMFT of permanent teeth was 0.75, 0.69, and 0.65 upon clinical examination, dental-teledentistry examination, and non-dental teledentistry examination, respectively. In primary teeth, dental teledentistry and non-dental teledentistry examinations showed 95 and 98.3 sensitivity and 94.3 and 91.4 specificity, respectively. In permanent teeth, dental teledentistry and non-dental teledentistry examinations showed 80.8 and 88.5 sensitivity and 94.1 and 96.1 specificity, respectively. Conclusions: Teledentistry has acceptable accuracy for caries detection in schoolchildren compared to a clinical dental examination.
Article
Introduction Teledentistry in orthodontics is growing, yet patient preferences for its use is unknown. This study aimed to determine the perceived value of doctor-to-patient face-to-face interaction, convenience, and attitudes toward specific uses of teledentistry among orthodontic patients. Methods Private practice orthodontists emailed an electronic survey to active patients. Patients aged ≥18 years completed the survey regarding their treatment. Parents of patients aged <18 years completed a separate survey regarding their child’s treatment. Responses were compared on the basis of patient characteristics (adult vs child, braces vs clear aligners, etc). Results Three hundred and eighty-eight respondents from 8 orthodontic practices participated in the survey. Eighty-five percent of parents considered face-to-face interaction important, and 85% said that their child’s treatment fit conveniently into their schedule. Adult responses were 86% and 89%, respectively. Adult preference for face-to-face was significantly higher than parents of adolescent patients (83% vs 78%; P = 0.038). Adults treated with clear aligners were less likely to strongly agree that their treatment fitted conveniently in their schedule (51% vs 76% in braces; P = 0.0490) and were more likely to be interested in using teledentistry (27% vs 18% in braces; P = 0.0429). Conclusions Most orthodontic patients prefer to be seen face-to-face. This is due to the high value placed on face-to-face interaction with the orthodontist. Most patients do not consider their treatment inconvenient. Patients prefer that teledentistry be used to enhance communication as opposed to replacing face-to-face interaction. Implementing teledentistry in orthodontics should be applied on a patient-to-patient basis with continued emphasis on the doctor-patient relationship.
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Background: Children's oral health is influenced by several factors related to their mother's condition. Mothers who have poor oral health generally have high anxiety about dentists and will rarely visit dental health services so their children will have poor oral health and oral problems will arise, especially caries. This has a negative impact on the quality of life of children. This study aims to determine the effect of maternal dental anxiety and child caries status on the quality of life of school children in an elementary school in Medan City. Methods: A cross-sectional design was conducted with 71 students, 6 until 7 years-old elementary schools in Medan. Maternal dental anxiety was measured using a Dental Anxiety Scale (DAS) questionnaire and children's quality of life was measured using a Parental Perception Questionnaire (PPQ). The child's caries status was assessed by taking with a smartphone camera and calculating the presence or absence of caries in each child. Results: Caries prevalence in children was 29.6%, maternal dental anxiety 88.7% low, 2.8% high anxiety. The mean score of maternal anxiety was 10.04± 3.46 and the child's quality of life score was 22.48±13. There is a significant effect between caries status and oral symptoms (p-value= 0.012) and functional limitations (p value = 0.039). Conclusion: Mothers who have high anxiety about dental care will ignore visits to the doctor. If there are dental and oral problems such as caries in children, this condition becomes protracted and affects the quality of life of children. Keywords: Caries, Dental anxiety, Maternal, Oral health, Quality of life
Preprint
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In the 21st century, health systems have to cope with the challenges posed by their rapidly changing socioeconomic, ecological, technological, demographic and epidemiological environment. Among these, the use of digital health solutions is an opportunity to make health systems better, but also a compelling force to change, which disrupts the traditional organizational and operational framework of medical care. This study is based on a survey of the dental care provided by three units (Oral Medicine, Periodontology, Orthodontics) of the Department of Community Dentistry, Semmelweis University, Budapest. During a period of 12 weeks, we have collected time balance data on 1131 patients, 539 in the traditional and 592 in a pilot teledentistry setting, in order to estimate how much time could be spared by monitoring patients through videoconferencing instead of face-to-face visits. According to our findings, teledentistry has the potential to shorten the visit with an average of 5-10 minutes per patient, which adds up to 58-116 work hours in a year. If the pilot was rolled out to all the 13 chairs of the surveyed 3 specialties (orthodontics, periodontology and oral medicine) the time saving would sum up to 186 workdays in one shift alone, which would translate to close to 4,500 additional patients per year, considering remote patient monitoring cases alone. Further, if inactive doctors and highly qualified dental hygienists were involved in delivering telecare, 2,67 times as many workdays could be spared, which would allow about 12,000 more patients treated per year. The rapid development of digital health technologies coupled with the evolving task distribution between health professionals have a great potential to improve health system performance in pursuit of population health. Unfortunately, the adaptation to these technological changes is uneven, and without a national strategy, the poor will unlikely benefit from these opportunities in public dental care.
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Objective This study was conducted to evaluate the validity and reliability of intraoral photographic assessments by different members of a dental team as a means for dental screening in children.Methods The intraoral photographic records of 126 children (2 to 18 years old) were obtained from routine clinical records taken before dental treatment. Intraoral photographs were obtained using a DSLR camera and then uploaded to a cloud-based server using store-and-forward telehealth technology. Images were reviewed by an expert panel to formulate a benchmark screening baseline, to which the screeners' data were compared. The photographic assessments conducted by a mid-level dental practitioner (MLDP) and dentist, were compared to the benchmark expert panel assessment.Results The screeners' assessments by means of intraoral photography, when compared to the expert panel assessment had a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between the expert panel assessment and photographic method (assessed by a dentist and MLDP), was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT/dft score for the children as determined by the expert panel's review and photographic assessment ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746).Conclusion Our results suggested that oral health professionals (other than dentists) have the potential to screen for caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists. This strategy has implications for supporting the use of MLDPs such as dental therapists or hygienists to screen for oral disease using telehealth.
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The uneven distribution of dental practitioners (particularly consultants – in Australia commonly called specialists) in Australia creates a barrier to accessing consultant level dental care. This maldistribution often results in the isolation of general dental practitioners (GDPs) practising in rural/remote settings, and the consequent lack of easy access to a second expert opinion from dental consultants. It then becomes challenging for GDP’s to weigh up cases that need consultant advice. This, at times, can contribute to under-referral or unselective referral of patients that require consultant advice, furthering the burdens on rural residents through additional travel and increased waiting times.
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Objectives: This study aimed to determine whether intraoral photographic assessment by mid-level dental providers (MLDPs) offers a valid and reliable means of dental caries screening. Methods: A mobile teledentistry model was developed to facilitate the acquisition of dental images, and transmission and reviewing of data. One hundred regularly attending patients at a dental clinic participated in the study. Following an on-site clinical examination by a senior dentist, photographs of participants' teeth were taken by a teledental assistant, using a smartphone camera. These intraoral photographs were directly uploaded from an Android App to a cloud-based server, 'Remote-i', using an encrypted store-and-forward telemedicine technology. The photographic assessment carried out by two independent screeners (MLDPs), was compared to the visual oral examination scores of a benchmark examiner. Results: The sensitivity and specificity values for the photographic assessment method (assessed by screeners) as compared to the direct visual examination ranged from 60% to 68%, and 97% to 98%, respectively. The intra-rater reliability for the photographic assessment was almost perfect, with a kappa score of 0.89. The inter-rater reliability between the photographic and visual oral assessments ranged from moderate to substantial agreement, with kappa scores ranging from 0.57 to 0.61. Conclusion: A new smartphone-based mobile teledentistry model used by mid-level dental providers shows potential for remote screening of dental caries.
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Objective: This study aimed to evaluate users' acceptance of a teledentistry model utilizing a smartphone camera used for dental caries screening and to identify a number of areas for improvement of the system. Methods: A store-and-forward telemedicine platform "Remote-I" was developed to assist in the screening of oral diseases using an image acquisition Android app operated by 17 teledental assistants. A total of 485 images (five images per case) were directly transmitted from the Android app to the server. A panel of five dental practitioners (graders) assessed the images and reported their diagnosis. A user acceptance survey was sent to the graders and smartphone users following completion of the screening program. Results: Of the 22 surveys sent out, 20 (91%) were completed. Generally, users showed optimism towards the use of the teledentistry system, and strongly positively assessed items on content and service quality. The majority of graders took less than 15 min to read the images while phone users took 5-10 min to complete the dental photography using the Android app. This study identified a number of factors that are essential for improving the current system, such as optimization of smartphone camera features, the format of the server, and the orientation of images and using oral retractors during photography. Conclusions: Users appear to be generally satisfied with the proposed teledentistry model. However, they have specific concerns to address, many of which could be resolved through more effective training, coordination between sites and upgrading the current system.
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Introduction: Access to ear and hearing health is a challenge in developing countries, where the burden of disabling hearing loss is greatest. This study investigated community-based identification of hearing loss using smartphone hearing screening (hearScreen™) operated by community health workers (CHWs) in terms of clinical efficacy and the reported experiences of CHWs. Method: The study comprised two phases. During phase one, 24 CHWs performed community-based hearing screening as part of their regular home visits over 12 weeks in an underserved community, using automated test protocols employed by the hearScreen™ smartphone application, operating on low-cost smartphones with calibrated headphones. During phase two, CHWs completed a questionnaire regarding their perceptions and experiences of the community-based screening programme. Results: Data analysis was conducted on the results of 108 children (2-15 years) and 598 adults (16-85 years). Referral rates for children and adults were 12% and 6.5% respectively. Noise exceeding permissible levels had a significant effect on screen results at 25 dB at 1 kHz (p<0.05). Age significantly affected adult referral rates (p < 0.05), demonstrating a lower rate (4.3%) in younger as opposed to older adults (13.2%). CHWs were positive regarding the hearScreen™ solution in terms of usability, need for services, value to community members and time efficiency. Conclusion: Smartphone-based hearing screening allows CHWs to bring hearing health care to underserved communities at a primary care level. Active noise monitoring and data management features allow for quality control and remote monitoring for surveillance and follow-up.
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Full-text available
Objective: It is widely considered that telemedicine can make positive contributions to dental practice. This study aimed to evaluate a cloud-based telemedicine application for screening for oral diseases. Methods: A telemedicine system, based on a store-and-forward method, was developed to work as a platform for data storage. An Android application was developed to facilitate entering demographic details and capturing oral photos. As a proof-of-concept, six volunteers were enrolled in a trial to obtain oral images using smartphone cameras. Following an onsite oral examination, images of participants' teeth were obtained by a trained dental assistant. Oral images were directly uploaded from the smartphone to a cloud-based server via broadband network. The assessments of oral images by offsite dentists were compared with those carried out via face-to-face oral examinations. Results: A complete set of 30 oral images was obtained from all six participants. Out of 192 teeth reviewed, the proportion of ungradable teeth was 8%. Sensitivity and specificity of teledental screening were 57% and 100% respectively. The inter-grader agreement estimated for two examination modalities and between two teledental graders was 70% and 62% respectively. Findings indicate that the proposed system for screening of oral diseases can be implemented to provide a valid and reliable alternative to traditional oral screening. Conclusion: This study provided evidence that a robust system for store-and-forward screening for dental problems can be developed, and leads to the need for further testing of its robustness to confirm the accuracy and reliability of the teledentistry system.
Article
Rationale for study: Teledentistry is an effective and efficient means of increasing access to care for screening, referral and treatment. Practice restrictions and the undocumented concern that dental hygienists do not have the skill or knowledge to identify or diagnose a carious lesion impede access to care. Purpose: This study compared the identification of dental caries by both dental hygienists and dentists and by both clinical and teledentistry methods. Methods: A sample of 82 children 4-7 years of age attending an elementary school in Memphis, Tennessee, was selected for the study. Two clinical examiners, a dental hygienist and dentist, independently examined and charted dental caries and existing restorations separately on the children. Two teledentistry examiners, a dental hygienist and dentist, independently reviewed and charted dental caries and restorations from photographs obtained with the iPhone 4S. Dental charts for each child were converted to a decayed filled surface (DFS) score resulting in four scores for analyses. Results: Seventy-eight children met the inclusion criteria. The clinical dentist's and clinical dental hygienist's DFS scores resulted in Spearman's correlation of r = 0.99. Friedman's analysis of the four examiners' DFS scores found no significant difference (P > 0.10) between the teledentistry dental hygienist's and the clinical dentist's scores. Conclusions: A dental hygienist can identify dental caries in children 4-7 years of age from photographs as accurately as a dentist in the clinical setting.
Article
Objectives: The study aimed to determine the validity of a smartphone hearing screening technology (HearScreen™) compared with conventional screening audiometry in terms of (1) sensitivity and specificity, (2) referral rate, and (3) test time. Design: One thousand and seventy school-age children in grades 1 to 3 (8 ± 1.1 average years) were recruited from five public schools. Children were screened twice, once using conventional audiometry and once with the smartphone hearing screening. Screening was conducted in a counterbalanced sequence, alternating initial screen between conventional or smartphone hearing screening. Results: No statistically significant difference in performance between techniques was noted, with smartphone screening demonstrating equivalent sensitivity (75.0%) and specificity (98.5%) to conventional screening audiometry. While referral rates were lower with the smartphone screening (3.2 vs. 4.6%), it was not significantly different (p > 0.05). Smartphone screening (HearScreen™) was 12.3% faster than conventional screening. Conclusion: Smartphone hearing screening using the HearScreen™ application is accurate and time efficient.