Telehealth in oral medicine: Evaluation of app usability and satisfaction among public health system professionals

Abstract

Objective

Evaluate the usability and user satisfaction of an oral medicine application among public health professionals.

Methods

A cross-sectional observational study was conducted with 101 dentists registered in the application, determined through sample size calculation. Data were collected using an online questionnaire. The System Usability Scale (SyUS) was used to assess usability, and an adapted questionnaire evaluated user satisfaction. Variables influencing satisfaction and usability were also analyzed.

Results

Most participants were female (73.3%), aged between 20 and 59 years (98%), with up to 10 years of professional experience (73%). The majority had a specialization (81%), including 24.8% in Collective and Family Health, and 80.2% worked in Primary Health Care. The mean SyUS usability score was 91.25 (scale: 0–100), exceeding the threshold of 70 for a viable product. Participants expressed high satisfaction with the app's theoretical and clinical support. Suggested improvements included a lesion database, chat functionality, interactive notifications, expanded attachment capacity, training initiatives, and broader specialty coverage.

Conclusion

The application achieved high usability and satisfaction scores, proving essential, intuitive, and effective. It complements public health systems by supporting diagnosis and treatment, enhancing professional collaboration, and improving care quality while addressing continuity and problem-solving needs.

Keywords

mobile apps dentistry oral diagnosis health services

1 Introduction

The availability of Information and Communication Technologies and their overall accessibility have made the implementation of remote health services possible. This provides the conditions for responding to the contemporary challenges of healthcare systems, such as the overload on specialized services, the high volume of referrals, long waiting periods and the need for travel, combined with the shortage of specialized professionals.¹

In the evaluation of oral lesions, the immediacy of the synchronous mode may represent an early diagnosis and better prognosis in cases of oral cancer. According to the National Cancer Institute (INCA), an estimated 15,100 new cases of oral cavity cancer are expected in Brazil each year from 2023 to 2025, making it the fourth most common cancer among men in the Southeast region. In Brazil, remote consultations in dentistry are only allowed when the patient is personally supervised by a dentist who requests the opinion of a second professional. Synchronous teleconsultation can provide reliable remote diagnoses by supporting professionals in the management of oral lesions.²

Telediagnosis and teleconsultation emerge as alternative and complementary means in the diagnostic and decision-making process, demonstrating agreement with existing gold standard techniques. Recent studies show that while tele-diagnosis proves to be a valuable option for remote pathology reports, teleconsultations play a significant role in supporting professionals in the management of oral lesions. The use of telehealth constitutes a useful and applicable possibility when access to specialized services is restricted.^1,3

This approach facilitates early detection in scenarios with limited resources. Recent advances in technology allow remote monitoring and screening to detect oral cancer in its early stages. Teledentistry improves access to specialized care, reaching a greater number of cases and overcoming barriers such as geographical distance, providing guidance, acting in surveillance and allowing appropriate referral, avoiding delays in diagnosis.^4,5

Based on this, “Teleinterconsultation in Stomatology app in Paraíba” emerged as a strategy to bring health professionals distributed throughout the state closer together, being an important tool for counseling and diagnosing changes in the oral cavity, providing an optimization of care and proper management of patients. The application is intended for teleconsultations between dentists, sharing cases of diagnosis and suspected oral cancer. The use of this application seeks fast, effective communication, allows for the establishment of a synchronous or asynchronous dialogue flow and referral to more complex care units. The application is the result of the articulation of teaching-service-community, which aims to update and disseminate knowledge in the area, in addition to introducing the use of technologies in health, impacting the organization of the health care network and care management. Image-based diagnosis by a specialist may help primary dental care facilities in the decision of referral to special care.⁶

In this scenario, evaluating usability is crucial for improvemen⁷ since it should be considered as an important factor in the development of systems, from the design phase to its implementation. For this reason, information systems must be continually submitted to evaluation to verify whether their interface is, in fact, efficient and satisfactory for users.⁸

Thus, the present study aimed to evaluate the usability and satisfaction of professional's users with the Teleinterconsultation in Stomatology app in Paraíba.

2 Methodology

2.1 About the mobile application

This app was created using a free tool, the Google Glide→ platform, which features an intuitive and user-friendly interface. It facilitates both synchronous and asynchronous interactions among dental professionals specializing in stomatology in the state of Paraíba. This practice is legally compliant and supported by Resolution No. 226/2020 of the Federal Council of Dentistry (FCD).³

This application is in its first version and is available for download via a link sent to public health dentists in Paraíba. Currently, it is not available on the Android and iOS application platforms, such as the Play Store→ and App Store→, respectively.

The application includes interfaces for professional registration, case submission (through photo uploads by the professional), and communication with the consultant. Based on these photo submissions, the consultant provides a diagnostic opinion on the case and guides the professional on the appropriate course of action.³

As a strategy for promoting the application, we have the support of the State Department of Health which holds meetings with public service dentists approximately twice a year.

2.2 Study design

A cross-sectional and observational study, carried out with dentists who work in the public health service in the State of Paraíba.

This state is in the Northeast Region of Brazil. It has 223 cities, with approximately 4 million in habitants, and a Human Development Index (HDI) of 0.658.⁹ Furthermore, in December 2021, there were 1410 oral health teams linked to Family Health with coverage of 89.42%.¹⁰

This study was approved by the Health Sciences Center Research Ethics Committee (UFPB), through opinion n° 57818422.1.0000.5188, and was done in accordance with Resolution 466/12 of the National Health Council.

2.3 Universe and sample

All professionals registered in the app and/or who submitted clinical cases (n = 286), up to the time of the research were included in the study.

For the sample calculation, an anticipated frequency of 85% of the SyUS satisfaction score was established, with a confidence interval of 95%.⁷ The OpenEpi system (https://www.openepi.com/SampleSize/SSPropor.htm) was used, obtaining a minimum sample size of 101 individuals.

Our methodology involved sending a questionnaire via Google Forms to all the dentists who used the app (n = 286), accompanied by messages to encourage them to respond. Based on the sample calculation and the difficulty of the professionals’ participation, we collected the data until we reached the predetermined sample size (n = 101).

2.4 Usability and satisfaction

The instrument used included general and specific questions about the app: if you already knew and/or how you came to know the tool, if you used it or are using it, if you would use it in dental care and if you would recommend the app to other professionals, in addition to SyUS (System Usability Scale), and an adapted satisfaction questionnaire.¹¹

The SyUS was developed in 1986 with the aim of providing a measurement of users’ perceptions of the usability of a system.¹² It is considered an important tool to assess efficiency, effectiveness and satisfaction.¹³

This scale presents 10 items in which, for each one, the user responded on a scale of 1 to 5 where: 1 means Totally Disagree and 5 means Totally Agree. The SyUS score ranges from 0 to 100, in which, regarding usability, results below 68 points are considered “unsatisfactory” and above “satisfactory.”¹² In addition, other variables such as age, gender, years since graduation, specialization, location in the public sector and city were also included and we tried to identify the professionals’ variables related to satisfaction and usability of the application.

2.5 Data collection and analysis

Data collection was carried out through a questionnaire on the Google Forms platform by a single researcher who sent the instrument via electronic address (e-mail) and WhatsApp after registering in the app between June and October 2022. To increase the number of responses, periodic reminders were sent to participants by email and WhatsApp, encouraging them to complete the questionnaire. Furthermore, no financial or material incentives were offered for participation, ensuring that the responses reflected the professionals’ genuine experience with the app.

The responses were presented quantitatively and submitted to statistical analysis, using the Statistical Package for Social Sciences software (IBM-SPSS, Chicago, IL), where absolute and relative frequency calculations were performed, as well as the chi-square test (p < 0.05), in order to verify association between the variables.

3 Results

3.1 Characterization of the participants

Regarding the distribution of participants by municipality, there are 102 municipalities (45.7%), included in the app (n = 286), corresponding to all regions of Paraiba (Figure 1).

Figure 1.

Spatial distribution of professionals registered in the Teleinterconsultation in Stomatology App in Paraiba (August/2022).

101 dentists were included in the study, with a female predilection (73.3%), with an average age of 33 years. Among these, 84% (n = 85) work in primary care, and 24.8% (n = 25) have Collective and Family Health as their specialty. Additionally, 88.1% (n = 89) reported having internet access at their workplace.

Most professionals learned about the app through encouragement from municipal management (44.6%), referral from colleagues (28.7%), state management (24.8%) and continuing education (21.8%).

About using the app, the majority (80.2%) did not report difficulties. In addition, before knowing or using the app, 7.9% of dentists did not usually carry out an active search for cases of oral cancer and other alterations. After using the app, 69.3% felt more confident and safer to perform an active search and diagnosis of oral lesions.

3.2 Usability assessment: system usability scale (SyUS)

The average SyUS score presented was 91.25 points, therefore, it is considered satisfactory.

Furthermore, Table 1 shows the association between the dentists working in PHC in relation to the average SyUS score.

Table 1.
SyUS participant score distribution.

Variables N % Average SyUS Score (± s.d.) P value

Gender

Feminine 74 73.3 75.1 (±14.2) 0.737

Masculine 27 26.7 74.0 (±14.8)

Age range

Up to 29 years 51 50.5 75.6 (±14.5) 0.543

More than 29 years 50 49.5 73.9 (±14.1)

Years graduated

Up to 5 years 54 53.5 75.6 (±14.9) 0.536

More than 5 years 47 46.5 73.8 (±13.6)

Specialization

Dońt have 21 20.8 70.0 (±14.8) 0.519

Have 80 79.2 72.5 (±14.2)

Works at PHC

Yes 85 84.2 73.6 (±14.4) 0.047*

No 16 15.8 81.3 (±11.9)

Regular internet access at the workplace (computers with internet access)

No 12 11.9 72.5 (±15.2) 0.456

Yes 89 88.1 72.5(±14.2)

Variables	N	%	Average SyUS Score (± s.d.)	P value
Gender
Feminine	74	73.3	75.1 (±14.2)	0.737
Masculine	27	26.7	74.0 (±14.8)
Age range
Up to 29 years	51	50.5	75.6 (±14.5)	0.543
More than 29 years	50	49.5	73.9 (±14.1)
Years graduated
Up to 5 years	54	53.5	75.6 (±14.9)	0.536
More than 5 years	47	46.5	73.8 (±13.6)
Specialization
Dońt have	21	20.8	70.0 (±14.8)	0.519
Have	80	79.2	72.5 (±14.2)
Works at PHC
Yes	85	84.2	73.6 (±14.4)	0.047*
No	16	15.8	81.3 (±11.9)
Regular internet access at the workplace (computers with internet access)
No	12	11.9	72.5 (±15.2)	0.456
Yes	89	88.1	72.5(±14.2)

*Student t test: with statistical difference (p < 0.05).

Table 2 presents each item that makes up the SyUS. The scale's structure presents alternations between positive (odd items) and negative (even items) aspects, from which it is verified that, in all questions of positive evaluation, more than 70 participants agreed with the statement. Likewise, more than 60 disagreed when it came to a negative assessment.

Table 2.

Items that make up the SyUS with the distribution of study results.

	Totally disagree	Disagree	Neutral	Agree	Totally agree
1 Would like to use this app often.	–	3 (3.0%)	16 (15.8%)	43 (42.6%)	39 (38.6%)
2 The app is unnecessarily complex.	43 (42.6%)	43 (42.6%)	12 (11.9%)	3 (3.0%)	–
3 The app is easy to use.	–	3 (3.0%)	20 (19.8%)	57 (56.4%)	21 (20.8%)
4 I would need support from a tech support to use this app.	28 (27.7%)	42 (41.6%)	19 (18.8%)	5 (5.0%)	7 (6.9%)
5 The app's various functions were well integrated.	–	6 (5.9%)	27 (26.7%)	45 (44.6%)	23 (22.8%)
6 There is a lot of inconsistency in the app.	26 (25.7%)	47 (46.5%)	25 (24.8%)	3 (3.0%)	–
7 I imagine that most people can learn to use this app quickly.	–	5 (5.0%)	11 (10.9%)	52 (51.5%)	33 (32.7%)
8 The app is very complicated to use.	35 (34.7%)	49 (48.5%)	14 (13.9%)	2 (2.0%)	1 (1.0%)
9 I felt very confident using this app.	1 (1.0%)	7 (6.9%)	26 (25.7%)	38 (37.6%)	29 (28.7%)
10 I needed to learn several things before I could start using this app.	36 (35.6%)	35 (34.7%)	21 (20.8%)	7 (6.9%)	2 (2.0%)

3.3 Satisfaction with the app

Data related to satisfaction are shown in Tables 3 and 4.

Table 3.
Assessment of survey participants’ satisfaction.

Excellent Very good Good Reasonable Bad

n (%) n (%) n (%) n (%) n (%)

General Opinion 32 (31.7%) 38 (37.6) 26 (25.7%) 5 (5%) –

Ease of learning 20 (19.8%) 38 (37.6) 33 (32.7%) 10 (9.9%) –

Clarity and Objectivity 25 (24.8%) 36 (35.6) 32 (31.7%) 8 (7.9%) –

Satisfaction 23 (22.8%) 40 (39.6) 29 (28.7%) 6 (5.9%) 3 (3%)

	Excellent	Very good	Good	Reasonable	Bad
General Opinion	32 (31.7%)	38 (37.6)	26 (25.7%)	5 (5%)	–
Ease of learning	20 (19.8%)	38 (37.6)	33 (32.7%)	10 (9.9%)	–
Clarity and Objectivity	25 (24.8%)	36 (35.6)	32 (31.7%)	8 (7.9%)	–
Satisfaction	23 (22.8%)	40 (39.6)	29 (28.7%)	6 (5.9%)	3 (3%)

Table 4.

Evaluation of the satisfaction according to the need, frequency, assistance, consultant's response, learning, resources made available and indication of the app.

	N	%
How necessary do you rate the app?
Very necessary	68	67.3
Necessary	33	32.7
Not very/not even a little necessary	–	–
Little necessary	–	–
Not necessary	–	–
How often do you (or) use the app?
Always	6	5.9
Sometimes	41	40.6
Rarely	32	31.7
Never used it	22	21.8
Did it help your work?
Yes, totally	40	39.6
Yes, partially	29	28.7
No	5	5.0
Never used it	27	26.7
If you have forwarded a case via the app, do you consider the response sent by the consultant to be adequate?
Yes, totally	45	44.6
Yes, partially	9	8.9
No	5	5.0
Never sent a case	42	41.6
Do you consider that you acquired new knowledge from the answer sent by the consultant?
Yes, totally	44	43.6
Yes, partially	13	12.9
No	9	8.9
Never sent a case	35	34.7
Are the resources available in the app adequate?
Yes, totally	52	51.5
Yes, partially	23	22.8
No	-	-
Never sent a case	26	25.7
Would you recommend the app to other co-workers?
Yes	96	95
No	–	–
Maybe	5	5.0

Finally, an open field was inserted so that respondents could leave comments at the end of the survey if they wished. Among the suggestions, it was explicit that: “Bank of lesions for comparison purposes;” “Chat for clarification of doubts;” “Notification communicating the consultant's interaction;” “Increase the number of attachments;” “Training of professionals for its use” and “Possibility of expanding to other specialties.”

4 Discussion

Our app emerged as a support tool for professionals working in the public health service. Here, we present interesting data about the usability and satisfaction of the app, highlighting its importance in the diagnosis of oral lesions.

The results presented show that the app presents satisfactory usability, indicating its potential to fill gaps in care.^7,14,15 Usability is developed with a focus on the user, aiming at the quality of interactivity and adapting the current interface when necessary, with the aim of reducing failures in the system so that it responds to their expectations and needs.¹⁶ Evidence points to difficulties and inconsistencies in diagnosing oral lesions by dentists.^17–23 The present study shows that 7.9% of the dentists did not usually carry out an active search for cases of oral cancer and other alterations. This may result in late diagnoses of oral cancer, and this conduct may be associated with insufficient training in oral pathology and stomatology fields.^20,22

The factors associated with not carrying out an active search for these dentists are not knowing where to refer or not being sure of how to proceed. Unfortunately, this is a frequent situation in oral diagnosis, which many professionals consider themselves unprepared and inexperienced to perform biopsies.^20,22 Thus, it is important to emphasize the relevance of the app as a methodology to support and encourage changes in clinical conduct in view of these findings, considering that the application provides support for decision-making and direction within the HCN. Furthermore, it should be noted that biopsy procedure is simple and can be performed in primary care, the focus of the present work, since 84% of professionals are included in this level of health care.

In addition to use, it is essential to evaluate this type of technology since these tools have implications for people's lives, lead users to change attitudes and behaviors, in addition to enhancing care in favor of quality of life and health.²⁴ Some studies showed that the use of apps had significant approval and acceptance in terms of purposes and user satisfaction, highlighting the need for support by managers in having structures to produce useful tools for the primary health care.^8,25 The present result was consistent with the literature, especially related to the overall satisfaction found.

The use of the app helps health professionals in the qualification of assistance, in the provision of services and in the teaching-learning process. Thus, it is feasible to use teledentistry to support the decision-making process to provide specialized assessments and guidance, when necessary, in order to provide better assistance.^26–28 These app works as a didactic, interactive and relevant proposal for the dissemination of evidence-based practice, intensifying the clinical sense, favoring the integration between knowledge, research and practice.²⁹ Health-related apps are progressing and reaching an ever-increasing reach due to the exponential growth in Smartphone usage. This creates the need for health professionals to be informed and trained about its effectiveness.²⁶

Therefore, there is interest in carrying out training for the purpose of using the app evaluated: “My suggestion is that there be training and the creation of a didactic manual or tutorial for better handling and use of the resources available in the app.” Even with 21.8% of professionals who learned about this tool through continuing education, it is important to emphasize the need to invest in training for the diagnosis of oral lesions. Immediate execution of the diagnostic examination can contribute to early diagnosis and improved prognosis.^{17–19,21,23}

Teledentistry exams are valid, feasible and comparable to the visual exam for oral screening and the use of these tools can improve treatment, access to care and do not seem to significantly affect the professional's judgment when compared to the visual exam. Furthermore, one can reach the same conclusion and appropriate decision regarding the necessary treatment and referral using both modalities.^29,30

The dissatisfactions observed were justified by the difficulty in accessing the internet, in handling technologies and failure to continue care in the HCN after establishing a diagnosis provided by the consultants, but these are factors that are not directly related to the app's functionalities. The need for investment in human resources, infrastructure, connection and lack of support by managers are some of the barriers described in the literature for the implementation of these technological tools.^31,32

As strengths, the present is an unprecedented study that evaluated the use of an app with validated instruments with feedback on responses, in addition to the initial awareness of professionals through permanent and continued education to present the app within a clinical and social context, suggesting future investigations for research that consider the different realities and needs presented.^7,33 As limitations of the study, data collection was carried out over a short period, and we did not offer rewards to participants. Therefore, it was necessary to send periodic reminders to encourage responses. Nevertheless, these factors did not prevent us from reaching the required sample number.

5 Conclusion

The Teleinterconsultation in Stomatology app in Paraíba presented a high usability and satisfaction score, where users classified it as very necessary, in addition to presenting ease of learning, use, clarity and objectivity.

This tool proved to be a complementary and accessible alternative for collective oral health since it enables support for diagnosis, treatments, brings professionals together and qualifies assistance and care, guaranteeing support and resolution.

Footnotes

ORCID iDs

Maria do Desterro Andrêzza Souza Costa

Quemuel Pereira da Silva

Hélder Domiciano Dantas Martins

Paulo Rogério Ferreti Bonan

Edson Hilan Gomes de Lucena

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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	Excellent	Very good	Good	Reasonable	Bad
	n (%)	n (%)	n (%)	n (%)	n (%)
General Opinion	32 (31.7%)	38 (37.6)	26 (25.7%)	5 (5%)	–
Ease of learning	20 (19.8%)	38 (37.6)	33 (32.7%)	10 (9.9%)	–
Clarity and Objectivity	25 (24.8%)	36 (35.6)	32 (31.7%)	8 (7.9%)	–
Satisfaction	23 (22.8%)	40 (39.6)	29 (28.7%)	6 (5.9%)	3 (3%)