Telehealth in oral medicine: A cross-sectional evaluation based on a mobile application

1. Introduction

Teledentistry acts remotely employing Information and Communication Technologies (ICTs) [1]. The use of ICTs in healthcare started around 1994, by military personnel to assist American troops [2]. Since then, it has proven effective in the process of diagnosis, consultations, and the proposition of treatments, both in private and public health services [3].

The use of ICTs has recently become widespread and has been promising in several fields of health care. Recent studies show that telemedicine can assist in monitoring patients with asthma and chronic obstructive pulmonary disease [4], has important clinical relevance in reducing cardiovascular risk [5, 6], and, in patients with temporomandibular disorders, can help in accurate diagnosis and promotes rapid management [7]. Moreover, applications can be extended and could assist in monitoring patients who have mucositis and temporomandibular disorders, improving their condition [8, 9].

In Brazil, integrality is a principle of the Unified Health System (UHS), which guarantees integral and uninterrupted care to the individual. In this system, its entry is coordinated by primary health care, which should solve most cases. In this sense, oral health was added integrally and inseparably to UHS in 2004, when the National Oral Health Policy was instituted. This dental care network includes all levels of health care through reference and counter-reference systems.

In teledentistry, we have teleconsultation, which is the exchange of information between two dentists to promote better patient care. Thus, although the gold standard for care between health professionals and patients remains the face-to-face meeting, the use of telehealth constitutes a useful and applicable possibility when access to specialized services is limited.

In addition, the use of this modality in oral diagnosis has been gaining space [10, 11], and is considered a good tool in the diagnostic process, considering that 85% of dental surgeons have difficulty in detecting, diagnosing, and treating oral lesions [11, 12, 13]. With the pandemic period, it was possible to observe that this service became more essential in health care. Moreover, there is a scarcity in the literature of telediagnostic applications in mobile devices, and their use can help primary health care to increase reluctivity and ensure comprehensive care [1, 10, 14].

Thus, we aimed to perform a cross-sectional evaluation based on the mobile application for oral diagnosis using a mobile application focusing on a state experience in Brazil.

2. Methods

This was a retrospective, cross-sectional, and observational study. The data analysis of the app “Telehealth in Stomatology in Paraíba” was performed from May 2021 to November 2022.

This app was developed through a free tool, the Google Glide^® platform, which has an objective and self-explanatory interface that allows interaction between professionals synchronously and asynchronously in the specialty of stomatology for dental surgeons in the state of Paraíba. The practice performed by the app is legal and covered by Resolution No. 226/2020 of the Federal Council of Dentistry (FCD).

OPEN IN VIEWER

In the application, there are several fields illustrated in Fig. 1:

a)

Telehealth in Stomatology: provides an overview of the idea and design of the tool, the legal information, and guidance on how to perform the clinical examination and obtain good photographs for diagnosis (Fig. 1A).

Figure 1B highlights the other fields described below:

a)

Consultant: information about the registered consultants.

When the professional reports a case on the app, he is referred to one of the consultants. The consultant forwards the case data to the app’s discussion group, which has the participation of all consultants. All questions about the case are discussed until a consensus is reached, which will be forwarded to the professional through the responsible consultant.

Here, we analyzed the spreadsheets generated by the application with the registered professionals focusing on gender, age, city of service, and specialty of the professional. Furthermore, the case reports and the consultants’ opinions were also analyzed by looking for the most common oral alterations and the agreement between them.

Regarding the agreement, we divided the lesions into groups (reactive lesions, potentially malignant disorders, malignant neoplasms, and others). When the dentist issued a diagnostic hypothesis, we compared it with the consultants’ diagnostic hypothesis, which could agree or not. Then, we performed the concordance rate between them using the number of all cases in which there was concordance divided by the total number of reported cases.

The app has a team of 16 consultants, consisting of Ph.D. professors ( n = 2; 12.5%), postgraduate students ( n = 3; 18.7%), residents ( n = 10; 62.5%), and dentists working in the area ( n = 1; 6.3%). In addition, there are 286 registered professionals, with a mean age of 33.7 years, predominantly female (70.6%), working in primary care (80.1%), and general practitioners (43.0%) (Table 1).

Figure 2 shows the spatial distribution of professionals registered in the app in the cities of Paraíba (A: September 2021; B: April 2022; C: November 2022). Paraíba is a Brazilian state with 223 cities. Currently, the application has coverage of 52.5% (117 cities with registered professionals). There is a larger number of registered dentists in João Pessoa – the state capital ( n = 42; 14.7%) followed by Sousa and Cajazeiras (4.2%), and countryside cities 373 km and 470 km away from the capital, respectively. Even with some gaps in the central region of the map, there is a distribution in the countryside.

Regarding the number of cases, the app has 194 cases reported (an average of 10 cases per month). Data about hypotheses registered by dentists, suggested by consultants, and agreement between them are evidenced in Table 2. Reactive lesions such as traumatic fibroma, mucocele, and traumatic ulcers are the most suggested hypotheses reported by dentists (24.5%) and consultants (22.3%). Regarding the agreement, we had an overall diagnostic concordance rate of 66.4%.

OPEN IN VIEWER

This study presents an experience based on the mobile application for oral diagnosis in the state of Paraíba, located in Northeastern Brazil. This innovative application was implemented and, had more than 190 cases registered. The differential of our application consists of the ease of access (any cell phone can be used) by dentists who work in public service.

The earliest article on teledentistry was published in 1995 pointing out the possible advantages of implementing the use of telemedicine equipment for remote dental diagnosis and treatment in the U.S. Army, to contain travel and patient evacuation expenses [15]. Since then, studies on “Teledentistry”, “Mobile applications” and “Software” have applicability in the fields of orthodontics [16, 17], endodontics [18], cariology and dentistry [19, 20, 21], stomatology [22, 23], and tele education [24, 25].

Interestingly, we have had an exponential increase in articles in the area recently. Of the 333 scientific articles found in Scopus, 155 (46.4%) were published in the last years (2020, 2021 and 2022). This was largely due to the COVID-19 pandemic, in which in-person dental care was limited to emergencies and, in Brazil, was performed respecting the recommendations of the Federal Council of Dentistry and the National Health Surveillance Agency. Thus, to fill the gap of limited access to health services, telemedicine has been employed and regulated [26]. The use of these technological resources in dentistry can reduce physical contact and the consequent dissemination of the virus, through teleconsultations, teleorientation, telemetry, and telemonitoring. Thus, it enables communication between professionals, contributing to the diagnosis and establishment of the patient’s treatment plan with speed and accuracy [27].

A recent study evaluated the impact of tele-dentistry, as well as its advances in dental practice. Through an electronic questionnaire, most dental professionals recommended this tool as it improves clinical practice, especially in oral medicine [27]. Previous studies have already highlighted the importance of teledentistry in the practice of diagnosing oral lesions, as it allows agility, greater accuracy in diagnosis, and ease of specialized care [2, 3, 27, 28]. Subsequently, a study pointed out some limitations of using this technology. For example, the 2D photo and the low quality of the images (due to lack of proper equipment) could difficult the correct diagnosis [2]. In this context, our application has users in more than 50% of the cities of the state, highlighting the need for tools to provide specialized care to areas far from the metropolitan regions. Furthermore, we had some cases reported with insufficient information and low-quality photos that made it impossible to provide hypotheses.

In addition, there are some benefits from teledentistry as easy to access and apply to different realities where specialized care is not so accessible. On the other hand, there are some difficulties, such as the resistance of some professionals to adapt to these technologies, as well as the difficulty of some patients to handle them. Here, our mobile application provides a secure place for information exchange between professionals and consultant, sharing of images, and access to the patient’s medical record. In addition, our application has a simple interface, used only by dentists, with the possibility of referring the patient to a face-to-face service.

The feasibility of diagnosis performed by teledentistry has been investigated and considered as an auxiliary tool in this process, especially in cases of greater complexity (unusual clinical presentations), which makes the resolution of the case more difficult. One of the most important causes associated with late diagnosis and treatment is the fact that primary health care professionals have difficulty in identifying, diagnosing, and treating oral lesions which results in diagnosis delay, and wrong referral for secondary health care professionals [11]. Some similar studies using different tools have shown an agreement rate of 53.8% [29], 82% [30], 26.88% [31]. In our study, we found an overall agreement of 66.4% through descriptive analysis which shows that primary care professionals require continued education and consultants’ information needs to be better described.

Throughout this period, we adopted some strategies for adherence to the application, such as meetings with the support of the state health secretary and training for the state’s dental surgeons in diagnosis, exemplified by Fig. 2. In addition, we had some important points such as suspected cases of sexual abuse in children and the celerity of the diagnosis of malignant cases (more than 25 cases), which is always a challenge for us.

Nevertheless, this study has limitations. The first is the adhesion of the application by the professionals. In Paraíba, according to DataSus (November 2022), we have 1442 oral health teams and 286 dentists registered in the application (19.8%). Positively, we have frequent meetings with the state health secretary for dissemination of the application and we expect to have more dentists registered soon. Another limitation is the difficulty in reporting cases, including some without providing sufficient data for us to establish diagnostic hypotheses. However, the number of incomplete cases that precluded our opinion is relatively low.

5. Conclusion

Given the above, the app is being well executed, with the adherence of professionals in Paraíba, and demonstrates usefulness in helping the diagnosis of oral and maxillofacial lesions, enabling an approach of dental surgeons from primary and secondary care to a specialized and quick opinion in Stomatology. Moreover, the literature reinforces the capacity of support and resolutive, as well as encouraging the development of innovative tools such as ours.

Funding

The study was supported by FAPESQ-PB.

Ethical approval

The authors wish to declare that all experiments on human subjects were conducted following the Declaration of Helsinki. Ethical approval for this study was obtained from the local ethics committee (No. 5.428.229).

Author contributions

HDDM contributed to the research, preparation, review, and writing of the manuscript; CPL, MVOD and MDASC contributed to the data collection; QPS contributed to the writing of the manuscript; EHGL contributed to the critical analysis of the manuscript and research proposal; PRFB contributed to the research proposal, methodology, review, editing of the manuscript, supervision, and project management. All authors approved the final version of the manuscript.