Applications of teledentistry in dental practice:

a systematic review1
Aplicaciones de la teleodontología en la práctica odontológica:
revisión sistemática1
Natalia Fortich Mesa2, Vivi Hoyos Hoyos3

SYSTEMATIC REVIEW
1 This project was financed by Special Cooperation Agreement (Convenio Especial de Cooperación) No. 212-2019, resulting from a
COLCIENCIAS call for submissions.
2 DDS. MSc in Clinical Epidemiology. Professor, Corporación Universitaria Rafael Núñez. Cartagena (Colombia). ORCID: 0000-0003-
2929-0278
3 DDS. Corporación Universitaria Rafael Núñez. Cartagena (Colombia). ORCID: 0000-0002-3085-7772
Abstract
Introduction: access to dental services in rural and remote areas is a problem still to be solved; for this
purpose, a new alternative known as teledentistry has emerged. Through the application of information
and communications technologies (ICTs), teledentistry promotes prevention, diagnosis, and treatment.
This study aimed to determine the impact of teledentistry applications on clinical practice in different
specialties based on the current evidence in the literature. Methods: two reviewers conducted a literature
search in PubMed, EMBASE, EBSCO, ScienceDirect and LILACS databases until August 2019, to identify
studies published in English, Spanish and Portuguese. Studies containing interventions applied to teledentistry,
published in the last six years and available in full text were included. Bias risk was assessed through validated
criteria according to each study type. Results: the search strategy retrieved 1028 articles, 24 of which
were selected for evaluation. Twenty-three articles were cross-sectional studies and only one study was
Keywords: quasi-experimental. Seventeen studies (70.8%) considered teledentistry as an alternative to diagnosing and
teledentistry, treating oral diseases in rural areas and health centers through mobile devices and clinical photographs.
health promotion, Most studies had moderate to high bias risk. Conclusion: while there is evidence on the use of teledentistry
diagnosis, oral in the various fields of dentistry, it is important to keep in mind that since this is a novel tool that seeks to
health, distance support access to health services in remote areas, the obtained results are preliminary, and further research
education with quality publications is necessary to evaluate the effectiveness of this tool.
Resumen
Introducción: el acceso a los servicios odontológicos en zonas rurales y remotas es una problemática que aún
no está resuelta, por lo que se ha introducido la teleodontología, a través de la aplicación de tecnologías de
la información y la comunicación (TICs) por medio de la prevención, diagnóstico y tratamiento. El objetivo
del presente estudio consistió en determinar el impacto de las aplicaciones de la teleodontología desde
las diferentes especialidades a partir de la evidencia. Métodos: dos revisores realizaron una búsqueda en las
bases de datos PubMed, EMBASE, EBSCO, ScienceDirect y LILACS para identificar estudios publicados
en inglés, español y portugués. Se incluyeron estudios que contenían intervenciones en teleodontología,
publicados en los últimos seis años y en texto completo. La calidad de los artículos se evaluó teniendo en
cuenta el diseño del estudio. Resultados: se identificaron 1028 artículos, y se incluyeron 24 artículos para
su evaluación. Veintitrés de estos artículos eran estudios transversales y un solo estudio fue de intervención.
Palabras claves: Diecisiete estudios (70,8%) presentaron la teleodontología como una alternativa para diagnósticos
teleodontología, y tratamientos de enfermedades bucales en zonas rurales mediante dispositivos móviles, consultas y
promoción fotografías. La mayoría de los estudios presentaban un riesgo de sesgo de moderado a alto. Conclusión:
de la salud, pese a que existe evidencia sobre el uso de la teleodontología en los diferentes campos de la odontología,
diagnóstico, salud es importante tener en cuenta que, dado que esta es una herramienta novedosa que busca apoyar el acceso
oral, educación a a los servicios de salud en zonas remotas, se hace necesario realizar una nueva búsqueda de evidencia con
distancia mejor calidad en la publicación.
Submitted: November 28/2019 – Accepted: April 14/2020

How to quote this article: Fortich-Mesa N, Hoyos-Hoyos V. Applications of teledentistry in dental

practice: a systematic review. Rev Fac Odontol Univ Antioq. 2020; 32(1): 77-88. DOI: [Link]
org/10.17533/[Link].v32n1a8

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 Applications of teledentistry in dental practice: a systematic review

INTRODUCTION In Latin America, specifically in Brazil,

Fonseca et al11 evaluated the correct
Telemedicine refers to the provision of me- diagnosis of the presence of oral lesions
dical care with Information and Commu- and diagnoses conducted remotely through
nication Technologies (ICTs) to conduct digital images obtained with a cell phone,
diagnostics, consider treatments, prevent di- showing improved efficiency and higher
seases, and strengthen the network of pro- demands in the provision of health services
fessionals and research activities in rural and and a decrease in inequalities in dental
hard-to-reach communities.1,2 Similarly, in clinical care.12,13 In Colombia, the concept
dentistry, an innovative method called tele- of telehealth was implemented through Law
dentistry has been developed, providing cli- 1419 of 2010, as a means of supporting the
nical care through electronic dental records General System of Social Security in Health
and remote ICTs as an opportunity to raise (Sistema General de Seguridad Social en
awareness, promote education and provide Salud, SGSSS), in order to support health
patients with professional services.3-6 service providers in terms of equity in care,
improved access to health services, and
This concept was first implemented in
quality of life in vulnerable areas.14
dentistry in 1997 by Cook,4 who used video
conferencing for diagnosis and remote However, the implementation and
treatment consultations, and managed applicability of telehealth to date is still
to exchange clinical information and inconclusive because the development and
images.7 Currently, this alternative is still application of these remote methods are
in development as a promising tool to recent, and therefore teledentistry is still
identify the presence of injuries and perform unknown to many professionals, preventing
teleconsultation in school programs, rural the population from receiving the benefits
areas, and areas with limited access through of these practices. Therefore, a systematic
different devices such as smartphones, review of the literature was conducted
portable x-rays, social networks, and in to determine the impact of teledentistry
various specialties such as endodontics, oral applications in various specialties in clinical
surgery, periodontics, and public health, practice based on available scientific
proving to be more efficient and with high evidence.
demand in the provision of health services,
thus reducing inequality in dental clinical
care.8,9 METHODS
Globally, research projects like the ones
conducted by Kale S, Kakodkar P, Shetiya A systematic search of the literature was
SH10 in India assessed mothers’ abilities for conducted to describe and summarize the
health education regarding the diagnosis of information available on the applications
tooth decay, using smartphone photographs, of teledentistry, following the PRISMA-P
which were sent through a social network. guidelines (2015).15
Each child’s diagnosis was requested, with Eligibility Criteria
significant changes for mothers, who made
improvements in the diagnosis of their Eligible studies were independently selected
children’s dental condition. by two reviewers who used titles and

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 Applications of teledentistry in dental practice: a systematic review

abstracts, including descriptive analysis, medicine AND teledentistry”; “telemedi-

cross-sectional studies and/or interventions cine AND oral health”; “teledentistry AND
in relation to teledentistry, published in the health promotion OR oral health”; “tele-
period 2013 to August 2019, available in odontología AND educación a distancia”;
full text in English, Spanish or Portuguese. “teleodontología AND salud oral”. The
Other study types, such as literature reviews, search strategy was adapted for each da-
systematic reviews, or documents submitted tabase.
as editorials or books were excluded.
Selection of studies and data extraction
Search Strategy For the selection of studies, two authors
Eighteen bibliographic searches were examined the publications’ titles
carried out using the PubMed, EM- independently and in duplicate based on the
BASE, EBSCO, ScienceDirect and LI- eligibility criteria; then the abstracts were
LACS databases from 2013 to August accessed, deciding which articles to include.
2019. These searches were carried out In the second evaluation stage, the articles
through the combination of the following were obtained in full text and evaluated by
keywords: “teledentistry AND education the two authors, who agreed by consensus
on the final inclusion.
distance”; “teledentistry AND health pro-
motion”; “teledentistry AND oral health”; The selected articles were broken down
“teledentistry AND NOT telemedicine”; in an evidence table (Table 1). The first
“teledentistry OR telehealth AND health reviewer extracted each full text, while the
promotion AND oral health”; “telehealth second reviewer independently verified
AND telemedicine AND teledentistry”; the extracted data and resolved the
“teledentistry AND oral health”; “tele- discrepancies generated at this stage.

Table 1. Characteristics of included studies

First Research Outcome (Area

Year Country Context Population involved Tool used
author design to evaluate)
AlKlayb 18
2017 Saudi Arabia Doesn’t report Mothers D Oral health Mobile app (iTeethey™)
Oral cancer / Cervical
Bhatts19 2018 India Rural area Adults C Interview
cancer
Birur20 2019 India Industrial zone Adults A Oral cancer Mobile app
Dental professionals and
Boringi21
2015 India University D Knowledge and beliefs Questionnaire
students
Daniel22 2017 United States Schools Children D Tooth decay Photographs
Almeida 23
2017 Brazil University Children and adults DT Dentoalveolar trauma Photographs
Dentists, dental students,
Estai24 2017 Australia Rural area D Tooth decay Questionnaire
dental therapists, nurses
Estai25 2016 Australia Doesn’t report Adults DT Oral diseases Mobile app
Estai26 2016 Australia Dental clinic Children and adults DT Tooth decay Mobile app
Giradeau 27
2017 France Prison Prisoners DT Oral health Camera (Soprocare®)
Haron28 2017 Malaysia Doesn’t report Adults DT Oral cancer Mobile device
Digital Fluorescence
Jung29 2018 South Korea University Adults DT Tooth decay
(QLF-D)

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 Applications of teledentistry in dental practice: a systematic review

First Research Outcome (Area

Year Country Context Population involved Tool used
author design to evaluate)
Kohara 30
2018 Brazil University Teeth extracted, Children DT Tooth decay Mobile device
Martin31 2016 United States Doesn’t report Dental Professionals D Telehealth Questionnaire
Students in dentistry, oral heal-
McFarland32 2017 United States Rural area D Teledentistry Questionnaire
th, and other health professions
McLaren33 2016 New York Rural area Children D Teledentistry Teledentistry consultation
McLaren 34
2016 New York University Children D Dental treatments Teledentistry consultation
Morosini35 2014 Brazil Prison Adolescents DT Tooth decay Photographs
Paixcao 36
2018 Brazil Health centres Teleconsulting D Teledentistry Database
Puhorit37 2017 India Rural area Children DT Tooth decay Camcorder
Distance
Roxo38 2017 Australia Dentists, nurses, dietitians A Oral cancer Virtual course
education
Skandarajah 39
2017 India Health centre Adults PB Oral cancer Mobile microscope
Midwest Caries IDTM
(MID), Visual Photo
Examination (CAM),
Van Hilsen40 2013 United States Doesn’t report Teeth extracted QE Tooth decay
Cross-polarization
Optical Coherence Tomo-
graphy (CP-OCT).
Vinayaga-
2019 India Rural area Adults O Oral cancer Mobile App (WhatsApp)
moorthy41

D: Descriptive; DT: Diagnostic Test; A: Analytical; CE: Quasi-experimental; O: Observational; C: Qualitative

Source: by the authors

The selected aspects for each article are sectional studies and 1 intervention study.
classified by first author, country, context, Each study is detailed in Table 1.
study sample, study design, outcome, and
tool used for the application of teledentistry. Most studies were conducted in the United
States and India, as well as in countries
Bias risk in individual studies in South America, Asia, and Oceania. As
for population type, the rural area was
Bias risk was assessed according to each predominant. In terms of the intervened
study type, verifying cross-sectional studies population, eight studies were performed in
through a checklist by the Agency for adults, four in children, two in children and
Healthcare Research and Quality (AHRQ)16 adults, and one in adolescents. Other studies
and randomized clinical trials through the were in students, dental professionals, and
list of items for publication of the Cochrane other health-related professions; there were
Collaboration Tool.17 in vitro studies (teeth removed), and studies
conducted in prisoners and teleconsultation.
Concerning the area to evaluate, eight
RESULTS studies indicated tooth decay as the main
outcome, followed by oral cancer with six
The search strategy identified 1028 articles, studies. Finally, in determining the tool used
of which 24 were included in this systematic for each study, an application or a mobile
review (Figure 1). There were 23 cross- device was used in eight studies.

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 Applications of teledentistry in dental practice: a systematic review

Figure 1. Flowchart of assessed studies per PRISMA

Source: by the authors

Results of cross-sectional studies identified knowledge and beliefs about

teledentistry from college in students and
In total, seventeen (70.8%) of the 24 dental professionals, and six studies assessed
evaluated studies mentioned teledentistry the applicability and use of teledentistry for
as an alternative method in rural areas, health promotion and disease prevention
health centers, and prisons for diagnosing during consultation, through questionnaires,
and treating oral diseases such as oral interviews and databases in children,
cancer, tooth decay, and dentoalveolar mothers and other adults.
trauma through different means such as
applications and mobile devices: iTeethey™, Results of intervention studies
WhatsApp, Remote-I, mobile microscope,
digital fluorescence (QLF-D), Soprocare One quasi-experimental study was found,
photo camera®, teledentistry consultations, which evaluated and compared the vi-
and clinical photographs by dentists, sual and infrared detection methods to
specialists and health professionals such as identify early non-cavitated ex vivo demi-
nurses and nutritionists. Similarly, one study neralization through three tests to detect

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 Applications of teledentistry in dental practice: a systematic review

occlusal demineralization: Midwest Caries the injury. It also did not present diagnostic
ID™ (MID), visual photographic examina- values such as CAM for use in teledentistry.
tion (CAM), and cross-polarization optical
Bias risk analysis
coherence tomography (CP-OCT) on teeth
removed 1 to 2 weeks apart. The teeth were Of the included studies, 95% had moderate
to high bias risk. Table 2 shows the bias risk
then sectioned, and each lesion’s depth was
analysis for observational studies only. On
confirmed, reporting that MID and CP-OCT the other hand, the only intervention study
were helpful in detecting the presence of de- was considered to have low bias risk as
mineralization, though not in the depth of shown in Table 3.

Table 2. Quality assessment according to the Agency for Healthcare Research and Quality (AHRQ)
information (survey,

Quality assessment

Clarity in follow-up
data in the analysis
participants in the

Handling missing
exclusion criteria
records, review)

Data collection
and control of
Reports other
Inclusion and

response rate
Exclusions of

confounding
Consecutive
Time period

participants

Assessment
population

aspects of
evaluated
Source of

variables
analysis
Author

Purohit, et al (2017) + + + + – – – – + – N/A

Estai, et al (2015) + – – + – – – – + – N/A
Roxo, et al (2017) + + + + – – – – + – N/A
Paixao, et al (2018) + + + + – – + – + – N/A
Vinayagamoorthy, et al (2019) + + + + – – – – + – N/A
Giraudeau, et al (2017) + + + + + – – – + – N/A
Boringi, et al (2015) + – – + + – – – + – N/A
Estai, et al (2016) + – – + + – – – + – N/A
Skandarajah, et al (2017) + – – + + – – – + – N/A
McLaren, et al (2016) + + + + + – – – + – N/A
Kohara, et al (2018) + + + + + – – – + – N/A
Bhatts, et al (2018) + + + + + – – – + – +
Daniel, et al (2017) + + + + – – – – + – N/A
Martin, et al (2016) + + + + + – – – + – N/A
Jung, et al (2018) + + + + – – – – + – N/A
Haron, et al (2017) + – – + – – – – + – N/A
McLaren, et al (2017) + – + + – – – – + – N/A
de Almeida, et al (2017) + – + + – – – – + – N/A
Birur, et al (2019) + + + + – – – – + – N/A
Alklaybsa, et al (2017) + + + + – – – – + – N/A
Estai, et al (2016) + + + + – – – – + – N/A
Morosini, et al (2014) + + + + – – – – + – N/A

McFarland, et al (2017) + + – + – – – – + – N/A

+ Yes: Meets the assigned item – No: Does not meet the assigned item N/A: Not applicable

Source: by the authors

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 Applications of teledentistry in dental practice: a systematic review

Table 3. Quality assessment according to Cochrane Collaboration

Random sequence Concealing the Blinding participants Incomplete Selective Other

Author
generation assignment and staff results data reports bias
Van Hielsen, et al (2013) + + + + – N/A
+ Yes: Meets the assigned item – No: Does not meet the assigned item N/A: Not applicable
Source: by the authors

DISCUSSION region through clinical examinations using

the decayed, missing and filled teeth index
The concept of teledentistry includes the (DMF-t) and a standardized video recording
combination of the use of computers, of the oral cavity. Sensitivity (0.86) and
telecommunications technology, digital specificity (0.58) values were calculated for
diagnostic imaging services, devices videographic evaluation of tooth decay, and
and software for oral health analysis and concordance was evaluated using the Bland-
monitoring, through diagnosis and treatment Altman graph, concluding that teledentistry
recommendations in the distance.42 All the can be used as an alternative for dental cavity
aforementioned aids have been used in detection and for consultations in remote or
fields such as care, education, and public hard-to-reach areas.37
health due to easy access to remote areas,
and reduced time and costs for patients.43 Torres-Pereira et al evaluated the applicability
of telediagnosis in oral medicine through
Two teledentistry methods are practiced the transmission of clinical images by
nowadays: store and transmit and/ email to two specialists, using two clinical
or videoconferencing. However, its hypotheses for each case, which were
implementation is minimal, and a more compared with the biopsy results, showing
frequent use of this modality in the diagnosis that in 80% of cases at least one specialist
of pathological conditions is suggested.44 provided the correct diagnosis, showing that
the use of information technology provides
Pentapati et al evaluated the reliability of
an acceptable rate of correct diagnoses,
an intraoral camera in teledentistry for
thus supporting its application as a tool for
the detection of oral diseases through an
detecting oral diseases.46
examiner who was trained and calibrated
in an intraoral camera to take videos of the Regarding users’ satisfaction with the use
oral cavity, against clinical examination to of applications and mobile devices in
evaluate cavities, bacterial plaque, calculus, teledentistry, Estai et al evaluated users’
dental wear, and fluorosis in children, acceptance of a teledentistry model using
reporting significantly higher values with the Remote-I, a store and transmit telemedicine
use of the intraoral camera than with clinical platform, to assist in the detection of oral
examination (p = 0.001), by means of the diseases transmitted directly from the
Spearman correlation coefficient.45 application to the server, finding out that
users showed optimism towards the use
Similarly, Purohit et al evaluated the reliability
of the teledentistry system, and positively
of videography to detect tooth decay among
evaluated the items in terms of content and
12-year-old schoolchildren in a rural Indian
quality of service.24

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 Applications of teledentistry in dental practice: a systematic review

However, to achieve efficiency and quality developed in the U.S., Europe, Asia and
standards in teledentistry, it is necessary Australia. This may be due to economic
to adequately train professionals and factors (financing), poor access to networking
insist in instant response to avoid careless in rural areas, or because the studies are in
service, educating dentists in the practice of their pilot stage; it is therefore necessary to
teledentistry, including information on legal, conduct further studies with a significant
ethical and technological implications, as sample and related follow-up studies in Latin
well as clinical methods for patient care. American countries.
The findings of this systematic review
show that, while the use of teledentistry is CONCLUSION
recent, there are some studies evaluating
the knowledge, perceptions, and attitudes This review helped determine the impact
in teledentistry among dental students, of teledentistry in different dental areas.
general dentists and specialists, as well as However, most revised studies showed
the use of applications, mobile devices and limitations in terms of short-term use of
intraoral cameras for oral health education teledentistry and low level of evidence
and diagnosis of oral diseases such as tooth due to the methods and results obtained.
decay, periodontitis, and oral cancer, as It is therefore necessary to conduct further
well as the adherence to recommendations studies to evaluate the efficacy and follow-
provided by dentists. This provides an up of teledentistry services for consultation,
important source of information and advice diagnosis, and recommendations in dental
for health policy makers, service managers treatment, as it may be a viable alternative
and clinicians, resulting in increased access in the reduction of time, transfers, and costs.
to health services and dental consultation.47
Most evaluated studies have multiple
AUTHORSHIP STATEMENTS
limitations, and even though this review was
limited to the use of teledentistry in recent All persons who meet authorship criteria are
years, there appears to be scarce use of this listed as authors of this document, and all
technology. This review found out that there authors certify that they have participated
are only a few studies that help identify good in its planning, design, and development,
quality standards, since most studies did not as well as in the interpretation of results. In
show prior evaluations, and there was only addition, each author critically reviewed the
one experimental study, showing that the paper, approved its final version and agreed
degree of scientific evidence is currently poor. with its publication. No responsible signature
Similarly, while teledentistry has a high of the document has been omitted and the
potential for addressing needs in the rural criteria for scientific authorship are met.
population or in remote areas, the findings
of this review show that more than half of
the evaluated studies were performed in
ACKNOWLEDGMENTS
urban areas rather than rural environments, The authors thank COLCIENCIAS for its
or did not report the location where they contribution in the development of the
were conducted, and most studies were manuscript.

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 Applications of teledentistry in dental practice: a systematic review

CONFLICT OF INTEREST CORRESPONDING AUTHOR

The authors declare that they have no Natalia Fortich Mesa
conflict of interest. Corporación Universitaria Rafael Núñez
+57-5-6517088 Ext 1007
[Link]@[Link]
Centro Calle de la Soledad # 5 - 70
Cartagena de Indias, Colombia

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