Teledentistry in Practice: Literature Review

Saad Ahmed Khan, BDS, MSc,1 and Hanan Omar, BDS, MSc, PhD2 screening schoolchildren for signs of early childhood caries.3–6 Ama-
vel et al.7 supported the findings of Kopycha-Kedzierawski and co-
1
Conservative Department, Faculty of Dentistry, University workers and stated that further studies addressing the financial aspect
of Malaya, Kuala Lumpur, Malaysia. of teledentistry should be conducted.
2
School of Dentistry, International Medical University,
Kuala Lumpur, Malaysia. Oral Medicine and Diagnosis
The use of teledentistry in oral medicine and diagnosis was as-
sessed through a study conducted in Belfast, Northern Ireland, where
Abstract the authors used a prototype teledentistry system as part of a service
Teledentistry can be defined as the remote provision of dental care, improvement scheme and found that teledentistry may represent an
advice, or treatment through the medium of information technology, alternative approach to manage referrals in oral medicine.8 The
rather than through direct personal contact with any patient(s) in- feasibility of distance-diagnosis of oral mucosal diseases through e-
volved. Within dental practice, teledentistry is used extensively in mail and a store-and-forward image system was investigated using
disciplines like preventive dentistry, orthodontics, endodontics, oral transmission of digital images to distant consultants. Results revealed
surgery, periodontal conditions, detection of early dental caries, that distance-diagnosis of oral diseases can be an effective tool in
patient education, oral medicine, and diagnosis. Some of the key detecting oral lesions and that the involvement of more than one
modes and methods used in teledentistry are electronic health re- consultant improved diagnostic accuracy. The authors concluded
cords, electronic referral systems, digitizing images, teleconsulta- that primary care clinics can benefit from the use of digital cameras
tions, and telediagnosis. All the applications used in teledentistry and that teledentistry can improve the oral healthcare in remote areas
aim to bring about efficiency, provide access to underserved popu- where specialists are not available.9,10 Teledentistry has the potential
lation, improve quality of care, and reduce oral disease burden. to provide populations of underserved patients with much-needed
oral health services. In a study conducted by Summerfelt,11 tele-
Key words: telehealth, telemedicine, telecommunications dentistry was used as a tool to allow dental hygienists to provide oral
healthcare to underserved populations through communication with
Introduction a distant oral health team.

T
eledentistry applications involve electronic patient records,
diagnosis, clinical decision support systems, and patient Oral Surgery
education. Successful use of teledentistry in various dental In the field of oral surgery, an attempt was made to diagnose
applications has been reported in the literature.1 impacted third molars via teledentistry; the authors concluded that
diagnostic information obtained from teledentistry assessment was
Periodontics similar to the real-time assessment information obtained by clinical
The history of teledentistry goes back to 1994, when the first trial diagnosis.12 The efficacy of teledentistry for preoperative assessment
was conducted on 15 patients referred for periodontal surgery to a was evaluated in a study conducted by Rollert et al.13 Teledentistry
clinic 120 miles away from where they lived. Referral was based on consultation was conducted to assess the patient’s health condition to
intraoral images that were captured and sent with the help of a dental undergo surgery with general anesthesia without further preopera-
image management system to the specialist clinic. The periodontal tive testing, evaluation, or consultation. Results showed that 95% of
surgery was conducted, and following the surgical procedures, suture patients underwent the surgery with general anesthesia at a sched-
removal was conducted in their town clinic. New images were cap- uled appointment based on the results of the teleconsultation. The
tured and sent to the clinic. Results of this study revealed that 14 out study confirmed that teleconsultation could be as reliable as the
of the 15 patients avoided the return trip to the specialist clinic and traditional methods in providing preoperative evaluation. An addi-
felt that they had received good care.2 tional benefit of teledentistry in this study was the provision of a
cost-effective method in situations where the transport of the patient
Preventive Dentistry and Pediatric Dentistry can be difficult or costly.13 The need for teledentistry as part of the
Kopycka-Kedzierawski and colleagues conducted a series of referral systems for oral surgery was investigated through a postal
studies addressing the role of teledentistry in the detection and diag- questionnaire sent to general dental practitioners in Manchester,
nosis of early childhood caries through intraoral images; their results United Kingdom.14 Forty-eight percent of the participants were not
suggested that teledentistry could be a potentially efficient means of satisfied with the current referral system because of the backlog in

DOI: 10.1089/tmj.2012.0200 ª M A R Y A N N L I E B E R T , I N C .  VOL. 19 NO. 7  JULY 2013 TELEMEDICINE and e-HEALTH 565
KHAN AND OMAR

treatment and the traveling distance that some patients had to endure images. The results of this study suggested that remote recognition of
to reach the specialist. Based on the questionnaire results, Coulthard root canal orifices can be achieved through images transferred between
et al.14 concluded that there is a need to change the referral system for different locations with the aid of teledentistry.27
oral surgery specialist care. The use of smartphones to obtain a
specialist consultation was discussed by Aziz and Ziccardi15 in 2009. Prosthodontics
Smartphones provide fast transfer of digital images and free mobility In the field of prosthodontics a trial has been done to assess the
of the surgeon. Based on these two factors, efficiency of the con- performance of graduate students in the construction of overdentures
sultation is improved with subsequent improvement in maxillofacial in a university clinic and a rural clinic. The direct instructing tech-
care.15 nique and a teledentistry instruction medium were used in the uni-
versity clinic and the rural clinic, respectively. Toward the end of the
Orthodontics trial, the overdentures were evaluated for their functionality, in ad-
The involvement of teledentistry in orthodontic treatment was dition to subjective evaluation represented by completing the Oral
investigated in terms of the attitudes of dental professionals toward Health Impact Profile questionnaire for edentulous subjects before
teledentistry, treatment outcomes, referrals, and serving disadvan- and after treatment. Results revealed that overdentures produced
taged populations. The attitudes of orthodontists and general dental using a teledentistry instruction medium were similar to those pro-
practitioners were assessed toward teledentistry in publications by duced through direct instructions. The authors concluded that tele-
Stephens and Cook16 in 2002, Mandall et al.17 in 2005, and Bradley dentistry has the potential to improve access to care and improve the
et al.18 in 2007. The results showed that orthodontists and general dental service available to rural populations when referral to spe-
dental practitioners supported the use of teledentistry in making or- cialists is difficult.28
thodontics consultation more accessible to dentists and patients.16–18
Teledentistry consultation improved the outcome of orthodontic Patient Education
treatment conducted by general dental practitioners, although the A feasibility study was conducted to assess the use of interactive
general dental practitioners in this study showed concerns in relation real-time videoconferencing as a mode of oral hygiene training for
to excessive time spent in capturing images and transmission of in- adults with tetraplegia, and the satisfaction of the subjects was re-
formation.19 Referrals of orthodontic cases via teledentistry were dis- ported.29 An economic evaluation to assess a teledentistry project
cussed in several studies.20–22 Teledentistry was found to be an conducted in the United Kingdom revealed that teledentistry could
effective tool to control inappropriate referral of orthodontic cases to offer timely services to patients in remote areas and cost saving in the
the consultants. In addition to the dentist, patients also appreciated the long run. In this case teleconsultation can become a constant part of
role of teledentistry as it can improve the process consultation.23 In a dental service.30 The use of teledentistry was reported to be an effi-
study conducted to evaluate the reliability of orthodontists to receive cient tool to educate orthodontic patients in relation to minor
new patients based on their clinical photographs, store-and-forward emergencies that may be encountered during the course of treatment.
teledentistry yielded the same results as referrals made by the general These problems may be easily resolved using teleconsultation while
dental practitioners based on their clinical examination.19 Serving the patient is at home; such problems generally include rubber lig-
disadvantaged children was the aim of the study conducted by Berndt ature displacement and discomfort due to the appliance or irritation
et al.24 as they investigated the feasibility of the orthodontic services of cheeks. This approach was found to be reassuring to both patients
being provided by a general dental practitioner with a real-time su- and parents and has the benefit of limiting the need to visit the dental
pervision of an orthodontist. Results of the study revealed that tele- offices.31
dentistry is a viable tool to serve children with malocclusions when the
referral to an orthodontist is time and cost demanding.24 Future of Teledentistry
Teledentistry offers a wide variety of clinical applications ranging
Endodontics from patients’ records management, diagnosis, and clinical decision-
Involvement of teledentistry in endodontics goes back to 2000, when making. Teledentistry has the potential to provide underserved
a study was conducted by Baker et al.,25 and they found that telecon- patients with oral healthcare services. In addition to clinical appli-
ferencing interpretation of conventional radiographs for artificial and cations teledentistry can be a beneficial tool to decrease the disparity
in vivo periapical bone lesions lead to the same results as those obtained and ensure equality in provision of oral healthcare services. The
using a conventional viewbox. Later, teledentistry played a role in the technology used in teledentistry enables the fast transfer of images,
diagnosis of periapical lesions; digital extra- and intraoral images and files, and documents and provides access to these information for
radiographs of the lesions were transferred via the Internet, and an specialists and practitioners.
expert opinion was obtained.26 Recognition of root canal orifices using In spite of the large number of disciplines that can benefit from
teledentistry was evaluated using images acquired for endodontically teledentistry and the wide range of applications, limitations to the use
accessed teeth. Those images were presented to observers, and visible of information communication and technology still exist. The use of
canal orifices were marked using software. Eighty-seven percent of digital images in diagnosis can be a helpful tool to diagnose visible
observers managed to identify the correct root canal orifices through the lesions, but the images have their own shortcomings. The images

566 TELEMEDICINE and e-HEALTH J U L Y 2 0 1 3

represent a two-dimensional view of three- dimensional objects, and 16. Stephens C, Cook J. Attitudes of UK consultants to teledentistry as a means of
this can affect accuracy of diagnosis. Another limitation of images providing orthodontic advice to dental practitioners and their patients. J Orthod
2002;29:137–142.
is the quality of captured images, as teledentistry requires images
17. Mandall NA, Qureshi U, Harvey L. Teledentistry for screening new patient
of high quality that cannot be produced in every center/clinic in orthodontic referrals. Part 2: GDP perception of the referral system. Br Dent J
rural areas. That brings another challenge: that is, the cost of 2005;199:727–729.
teledentistry—supporting technology that can represent a burden on 18. Bradley SM, Williams S, D’Cruz J, Vania A. Profiling the interest of general dental
both governments and individuals. Evidence shows that teledentistry practitioners in West Yorkshire in using teledentistry to obtain advice from
is a fast-growing field with a lot of potential, but it is still in its infancy, orthodontic consultants. Prim Dent Care 2007;14:117–122.
and more emphasis needs to put on allocation of funds and grants to 19. Stephens C, Cook J, Mullings C. Orthodontic referrals via TeleDent Southwest.
Dent Clin North Am 2002;46:507–520.
conduct more clinical trials to provide more evidence and to identify
how teledentistry can play a role in the provision of oral healthcare. 20. Cook J, Mullings C, Vowles R, Ireland R, Stephens C. Online orthodontic advice:
A protocol for a pilot teledentistry system. J Telemed Telecare 2001;7:324–333.
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Disclosure Statement GDPs with advice in orthodontics. Dent Update 2002;29:249–255.
No competing financial interests exist.
22. Mandall N. Are photographic records reliable for orthodontic screening?
J Orthod 2002;29:125–128.
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Received: August 11, 2012
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