Teledentistry in Practice: Literature Review

Introduction

Teledentistry applications involve electronic patient records, diagnosis, clinical decision support systems, and patient education. Successful use of teledentistry in various dental applications has been reported in the literature. ¹

Periodontics

The history of teledentistry goes back to 1994, when the first trial was conducted on 15 patients referred for periodontal surgery to a clinic 120 miles away from where they lived. Referral was based on intraoral images that were captured and sent with the help of a dental image management system to the specialist clinic. The periodontal surgery was conducted, and following the surgical procedures, suture removal was conducted in their town clinic. New images were captured and sent to the clinic. Results of this study revealed that 14 out of the 15 patients avoided the return trip to the specialist clinic and felt that they had received good care. ²

Preventive Dentistry and Pediatric Dentistry

Kopycka-Kedzierawski and colleagues conducted a series of studies addressing the role of teledentistry in the detection and diagnosis of early childhood caries through intraoral images; their results suggested that teledentistry could be a potentially efficient means of screening schoolchildren for signs of early childhood caries. ^{3 –6} Amavel et al. ⁷ supported the findings of Kopycha-Kedzierawski and co-workers and stated that further studies addressing the financial aspect of teledentistry should be conducted.

Oral Medicine and Diagnosis

The use of teledentistry in oral medicine and diagnosis was assessed through a study conducted in Belfast, Northern Ireland, where the authors used a prototype teledentistry system as part of a service improvement scheme and found that teledentistry may represent an alternative approach to manage referrals in oral medicine. ⁸ The feasibility of distance-diagnosis of oral mucosal diseases through e-mail and a store-and-forward image system was investigated using transmission of digital images to distant consultants. Results revealed that distance-diagnosis of oral diseases can be an effective tool in detecting oral lesions and that the involvement of more than one consultant improved diagnostic accuracy. The authors concluded that primary care clinics can benefit from the use of digital cameras and that teledentistry can improve the oral healthcare in remote areas where specialists are not available. ^9,10 Teledentistry has the potential to provide populations of underserved patients with much-needed oral health services. In a study conducted by Summerfelt, ¹¹ teledentistry was used as a tool to allow dental hygienists to provide oral healthcare to underserved populations through communication with a distant oral health team.

Oral Surgery

In the field of oral surgery, an attempt was made to diagnose impacted third molars via teledentistry; the authors concluded that diagnostic information obtained from teledentistry assessment was similar to the real-time assessment information obtained by clinical diagnosis. ¹² The efficacy of teledentistry for preoperative assessment was evaluated in a study conducted by Rollert et al. ¹³ Teledentistry consultation was conducted to assess the patient's health condition to undergo surgery with general anesthesia without further preoperative testing, evaluation, or consultation. Results showed that 95% of patients underwent the surgery with general anesthesia at a scheduled appointment based on the results of the teleconsultation. The study confirmed that teleconsultation could be as reliable as the traditional methods in providing preoperative evaluation. An additional benefit of teledentistry in this study was the provision of a cost-effective method in situations where the transport of the patient can be difficult or costly. ¹³ The need for teledentistry as part of the referral systems for oral surgery was investigated through a postal questionnaire sent to general dental practitioners in Manchester, United Kingdom. ¹⁴ Forty-eight percent of the participants were not satisfied with the current referral system because of the backlog in treatment and the traveling distance that some patients had to endure to reach the specialist. Based on the questionnaire results, Coulthard et al. ¹⁴ concluded that there is a need to change the referral system for oral surgery specialist care. The use of smartphones to obtain a specialist consultation was discussed by Aziz and Ziccardi ¹⁵ in 2009. Smartphones provide fast transfer of digital images and free mobility of the surgeon. Based on these two factors, efficiency of the consultation is improved with subsequent improvement in maxillofacial care. ¹⁵

Orthodontics

The involvement of teledentistry in orthodontic treatment was investigated in terms of the attitudes of dental professionals toward teledentistry, treatment outcomes, referrals, and serving disadvantaged populations. The attitudes of orthodontists and general dental practitioners were assessed toward teledentistry in publications by Stephens and Cook ¹⁶ in 2002, Mandall et al. ¹⁷ in 2005, and Bradley et al. ¹⁸ in 2007. The results showed that orthodontists and general dental practitioners supported the use of teledentistry in making orthodontics consultation more accessible to dentists and patients. ^{16 –18} Teledentistry consultation improved the outcome of orthodontic treatment conducted by general dental practitioners, although the general dental practitioners in this study showed concerns in relation to excessive time spent in capturing images and transmission of information. ¹⁹ Referrals of orthodontic cases via teledentistry were discussed in several studies. ^{20 –22} Teledentistry was found to be an effective tool to control inappropriate referral of orthodontic cases to the consultants. In addition to the dentist, patients also appreciated the role of teledentistry as it can improve the process consultation. ²³ In a study conducted to evaluate the reliability of orthodontists to receive new patients based on their clinical photographs, store-and-forward teledentistry yielded the same results as referrals made by the general dental practitioners based on their clinical examination. ¹⁹ Serving disadvantaged children was the aim of the study conducted by Berndt et al. ²⁴ as they investigated the feasibility of the orthodontic services being provided by a general dental practitioner with a real-time supervision of an orthodontist. Results of the study revealed that teledentistry is a viable tool to serve children with malocclusions when the referral to an orthodontist is time and cost demanding. ²⁴

Endodontics

Involvement of teledentistry in endodontics goes back to 2000, when a study was conducted by Baker et al., ²⁵ and they found that teleconferencing interpretation of conventional radiographs for artificial and in vivo periapical bone lesions lead to the same results as those obtained using a conventional viewbox. Later, teledentistry played a role in the diagnosis of periapical lesions; digital extra- and intraoral images and radiographs of the lesions were transferred via the Internet, and an expert opinion was obtained. ²⁶ Recognition of root canal orifices using teledentistry was evaluated using images acquired for endodontically accessed teeth. Those images were presented to observers, and visible canal orifices were marked using software. Eighty-seven percent of observers managed to identify the correct root canal orifices through the images. The results of this study suggested that remote recognition of root canal orifices can be achieved through images transferred between different locations with the aid of teledentistry. ²⁷

Prosthodontics

In the field of prosthodontics a trial has been done to assess the performance of graduate students in the construction of overdentures in a university clinic and a rural clinic. The direct instructing technique and a teledentistry instruction medium were used in the university clinic and the rural clinic, respectively. Toward the end of the trial, the overdentures were evaluated for their functionality, in addition to subjective evaluation represented by completing the Oral Health Impact Profile questionnaire for edentulous subjects before and after treatment. Results revealed that overdentures produced using a teledentistry instruction medium were similar to those produced through direct instructions. The authors concluded that teledentistry has the potential to improve access to care and improve the dental service available to rural populations when referral to specialists is difficult. ²⁸

Patient Education

A feasibility study was conducted to assess the use of interactive real-time videoconferencing as a mode of oral hygiene training for adults with tetraplegia, and the satisfaction of the subjects was reported. ²⁹ An economic evaluation to assess a teledentistry project conducted in the United Kingdom revealed that teledentistry could offer timely services to patients in remote areas and cost saving in the long run. In this case teleconsultation can become a constant part of dental service. ³⁰ The use of teledentistry was reported to be an efficient tool to educate orthodontic patients in relation to minor emergencies that may be encountered during the course of treatment. These problems may be easily resolved using teleconsultation while the patient is at home; such problems generally include rubber ligature displacement and discomfort due to the appliance or irritation of cheeks. This approach was found to be reassuring to both patients and parents and has the benefit of limiting the need to visit the dental offices. ³¹

Future of Teledentistry

Teledentistry offers a wide variety of clinical applications ranging from patients' records management, diagnosis, and clinical decision-making. Teledentistry has the potential to provide underserved patients with oral healthcare services. In addition to clinical applications teledentistry can be a beneficial tool to decrease the disparity and ensure equality in provision of oral healthcare services. The technology used in teledentistry enables the fast transfer of images, files, and documents and provides access to these information for specialists and practitioners.

In spite of the large number of disciplines that can benefit from teledentistry and the wide range of applications, limitations to the use of information communication and technology still exist. The use of digital images in diagnosis can be a helpful tool to diagnose visible lesions, but the images have their own shortcomings. The images represent a two-dimensional view of three- dimensional objects, and this can affect accuracy of diagnosis. Another limitation of images is the quality of captured images, as teledentistry requires images of high quality that cannot be produced in every center/clinic in rural areas. That brings another challenge: that is, the cost of teledentistry—supporting technology that can represent a burden on both governments and individuals. Evidence shows that teledentistry is a fast-growing field with a lot of potential, but it is still in its infancy, and more emphasis needs to put on allocation of funds and grants to conduct more clinical trials to provide more evidence and to identify how teledentistry can play a role in the provision of oral healthcare.