Utilization of teledentistry in rural areas: a scoping review

Introduction

Background

Due to limited medical resources and geographical remoteness, the provision of dental care services for residents of rural areas is not always sufficient (1,2), with a distinct shortage of dentists in rural areas compared to urban areas (1-3). The proportion of people who maintain their oral hygiene is also reported to be lower in rural areas than in urban areas (4,5). Thus, there is a need to improve dental care services in rural areas.

Rationale and knowledge gap

Teledentistry using information and communication technology such as web-mail, smartphones, tablets, and computer systems has been noted as a new technology that provides dental care to rural areas and reduces the gap in care between rural and urban areas (6). During recent infectious disease pandemics, especially coronavirus disease 2019 (COVID-19), teledentistry has been used to access dental care services (7). Recent advances in imaging and artificial intelligence (AI)-related analyses, communication systems, and digital devices are expected to be helpful in teledentistry (8). However, a number of issues associated with teledentistry, such as little evidence of effectiveness, low preparation for acceptance by dentists and patients, and practical restrictions due to legal regulations, have been highlighted (9).

Objective

Teledentistry can be applied for a variety of purposes, including diagnosis, treatment, consultation, education, and training. Teledentistry is thought to be applicable remotely in dental care, even in rural areas; however, the utilization of teledentistry has not been fully understood. We intended to summarize empirical studies of teledentistry that were conducted in rural settings. Hereby, we reviewed the current state and potential of dental care services that apply teledentistry in rural areas, in particular. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-28/rc).

Methods

We searched MEDLINE/PubMed and CENTRAL (Cochrane CENTRAL databases for relevant Trials). The literature search was limited to publications published up to May 2024. This search was conducted in June 2024. Literature was limited to original articles, and conference abstracts, letters, editorials, and review papers were excluded. The policy recommendation and opinion papers were not included. The literature to be reviewed was selected based on the following views: the target populations were subjects living in rural areas. Studies that compared the application with non-application of teledentistry and the remote approach with face-to-face approach were eligible. Studies that did not always have reference populations were permitable. Studies that evaluated the feasibility and effectiveness of teledentistry as the outcomes were eligible.

Although we didn’t register the review protocol, in extracting the studies, the following search formula was used to extract keywords from the text contained in the titles and abstracts of the papers: (((teledentistry or tele-dent*).ab. or Teledentistry.ti.) and rural.af.) not review.ab. not Review.ti. In addition, we selected studies based on the titles and abstracts of the papers published in the Cochrane Database of Systematic Reviews. We excluded duplicates from the studies we extracted and the following studies: studies that targeted applications to dental professionals and students, studies that only described the research protocol, and studies that did not match our objectives and criteria. In the screening, one reviewer first extracted studies from the titles and abstracts based on the criteria. Next, the other reviewer checked the list, and finally, two authors reviewed the contents of the studies. The extraction and analysis processes for this review followed the methodology outlined by the Joanna Briggs Institute (JBI) (10,11).

The literature was assessed according to the evaluation items as evidence, system, and equipment provided. Image capture and remote communication equipment were used for research classification. The communication methods for teledentistry included synchronous real-time videoconferencing and asynchronous store-and-forward methods (12,13). Based on the content of each study, we considered the categories of application of teledentistry from the perspective of medical practice, as raised by the World Health Organization (14). For instance, screening (checkups) in the general setting, diagnoses in the setting of clinics and pathological/histological departments, referral/consultation with specialists, and oral health support were summarized as basic categorization (14).

Results

When searching for literature on teledentistry, we extracted 53 studies after removing duplicates, and 37 studies after after the exclusion criteria were met. In addition, although we searched for studies that could be confirmed as eligible based on the main text, we found no additional literature. Ultimately, 13 studies were identified, as shown in Figure 1. A list of the identified studies is presented in Table 1.

Figure 1 PRISMA flowchart to identify the literature.

Of the 13 studies identified, 4 were reported in the USA, 2 in Australia, 1 in the UK, 2 in India, 2 in the Kingdom of Saudi Arabia (KSA), and one from Iran and one jointly from Germany and France, as presented in Table 1. The subjects to be observed (including duplicates) were children ≤14 years old in 4 studies (18,19,22,25), residents of elderly care facilities in 2 studies (23,24), patients in 5 studies (16,20,21,26,27), dentists in 1 study (15), and facility staff in 1 study (23). The number of studied participants ranged from 13 to 1,621. The equipment used for image capture in teledentistry included dedicated devices for intraoral photography and cameras on the subjects’ smartphones. Five out of the 13 studies were conducted via real-time consultations (16,18-20,26), while the other 8 were conducted mainly using asynchronous methods, such as store-and-forward, which involves storing and using images and video (15,17,21-25,27).

The studies were divided into four categories based on the application of teledentistry. There were five studies on pathological diagnoses (15-17,20,24), four on dental screening (checkups) (18,19,22,25), two on oral health support (21,23), and two on referrals to specialists (26,27).

Pathological diagnoses

Five studies examined the accuracy of the pathological diagnosis. Akeel et al. examined the accuracy of its application in the diagnosis of severe oral lesions (15). This study used not only high-quality images taken by dentists but also low-quality images taken by the patients themselves. The dental specialists did not receive any information regarding the patients’ medical history and made diagnoses of oral lesions based on the images alone. The results showed that the diagnostic accuracy differed depending on the lesions, with the complexity of diseases affecting the results rather than the quality of the images (15). Flores-Hidalgo et al. compared the results of diagnoses made by dental specialists from images of oral lesions using both online synchronous and asynchronous methods with the results of biopsies using microscopic diagnosis (16). The diagnostic accuracy based on the results of biopsies was an F-score of 0.8 (an index that evaluates accuracy based on the precision rate and recall rate), indicating that it could play a supplementary role in definitive diagnoses (16). Tareq et al. investigated the accuracy of AI in diagnosing dental caries compared to actual dentists (17). They used unstandardized images taken using smartphone cameras. The diagnostic accuracy of the model was 86.96%, and caries could be accurately identified using image diagnoses with deep learning (17). Aboalshamat et al. conducted a randomized controlled trial (RCT) targeting dental patients ≥18 years old, comparing the accuracy of detecting dental caries and the decayed-missing-filled teeth index, and found that the remote diagnosis tended to overestimate disease risk (20). Queyroux et al. conducted a pathological diagnosis using intraoral videos of the residents of an elderly nursing home (24). Based on face-to-face diagnosis, the diagnosis was highly accurate, with a sensitivity of 93.8% and specificity of 94.2% (24).

Dental screening

Four studies described dental screening (checkups) for dental caries. Two of these studies examined the applicability of technology (18,19), and one evaluated the accuracy of screening (25). In addition, acceptance and satisfaction (19) and cost (22) for children, including preschool children, were examined.

In four studies, dental hygienists and other medical staff visited the subjects and transmitted images to remote dental specialists. Each study showed that the system can be efficiently implemented without significant problems. Ward et al. conducted dental examinations of preschool children using telehealth technology and found that the children’s dental examinations could be successfully completed (18). Agarwal et al. conducted remote dental examinations on children aged 6–10 years and compared them with regular face-to-face examinations, and the children showed a high level of satisfaction (19). Purohit et al. evaluated the reliability of screening for dental caries in children using images by comparing them with the results of face-to-face diagnoses by the same dentist on a different day. The intraclass correlation coefficient was 0.56, and the area under the receiver operating characteristic curve was 0.69 (25). Estai et al. conducted a study with children aged 5 to 14 years and showed a cost reduction, which could increase in more remote areas (22).

Oral health support

Two studies that applied teledentistry to oral health support programs were identified. Borujeni et al. found that video instruction, which could be viewed repeatedly, was more effective than one-time face-to-face instruction in improving oral hygiene in patients undergoing orthodontic treatment (21). Tynan et al. conducted teledentistry using oral health therapists for residents of elderly care facilities. They showed that it improved the oral hygiene management of residents and increased the quality of services at facilities (23).

Referrals to specialists

Two studies that used teledentistry for referrals to specialists were identified. Fricton et al. showed that remote consultation for patients with orofacial diseases, such as temporomandibular disorders and orofacial pain, was carried out in addition to face-to-face examinations. They also showed that it could reduce patients’ time traveling to and from the hospital (26). Mandall et al. compared new patients referred to orthodontics via a teledentistry system (intervention group) with those referred via a conventional letter (control group) and found that the rate of inappropriate referrals was significantly lower for those referred via the system than for those referred via a letter (27).

Discussion

We reviewed the utilization of teledentistry in dental care in rural areas. The studies in this review have been reported in various countries and populations. We divided its applications into the following categories: pathological diagnoses, dental screening (checkups), oral health support, and referrals to specialists. The time reduction in access to services, acceptable satisfaction, and potential cost reduction were partly described. The findings of this review imply the worldwide need, as well as the diverse and useful application of teledentistry in rural areas. Given the summary of the advantages and limitations of teledentistry from this review (Table 2), the spread of teledentistry is expected to help healthcare systems provide dental care in rural areas and mitigate the rural-urban gap of care, although more studies are required to overcome the limitations of teledentistry.

The age range of the study subjects was wide, ranging from children to the elderly (i.e., residents of elderly care facilities). Under a shortage of dental care professionals, including dentists, and geographical remoteness in rural areas where all generations live (1-3), a high need and burden are presumed for regular dental care and screening for people of a wide age range. This could be one of the reasons for the review results of subjects’ characteristics.

Of note, the main categories identified to apply teledentistry were dental diagnoses and screening (checkups). This could mean that teledentistry is applicable, and there is a high need for dental diagnoses and screening, which involves a large number of people and a limited number of dentists and resources, as it was repeatedly said (1-3). These studies evaluated the accuracy of teledentistry for diagnoses and/or screening, which are deemed to have comparatively high accuracy. The accuracy could also facilitate the application of teledentistry. Nonetheless, oversight and error of detection should be avoided even though the performance of imaging and communication equipment or devices has made it possible to capture and transmit high-precision images (20). Future studies should focus on advances in the diagnostic and screening systems using teledentistry.

On the other hand, generally, specialists are not always involved in screening, and definitive diagnoses require pathological diagnoses. It might be one of the reasons why there is little literature in clinical settings using teledentistry in this review. In a study that evaluated the accuracy of pathological diagnoses (17), a smartphone camera was used for image capture rather than an intraoral camera, and the appropriateness of the capture method and environment, such as brightness, was not investigated. Such factors might have reduced the accuracy, leading to further verification. In the future, the diagnostic accuracy of pathological diagnoses will increase due to advances in equipment and technology related to image capture and analysis, and pathological diagnoses using teledentistry may be more widely applied. This may be the same as referrals to specialists to directly see patients, as dentists in rural areas are known to have more difficulty using referral services than those in urban areas, and there could be a high need for remote referrals to specialists (28).

Of interest, the studies using real-time communication have been conducted (16,18-20,26). This synchronous method allows for two-way communication, which it is not all that different from face-to-face consultation for patients (26). This is assumed to have partially influenced the good satisfaction and acceptance of subjects receiving teledentistry seen in the studies in this review (19). However, a secure communication system must still be ensured for the exchange of medical information between patients and specialists.

As seen in a study that used a method of AI (17), advances in imaging and AI-related analyses, communication systems, and digital devices are expected to be incorporated into teledentistry (8,29). The use of AI has been reported to be effective for the diagnosis of diseases and tumors using images in the fields of oral radiology, oral surgery, and maxillofacial surgery (29,30). However, it is also argued that the application of AI in medical practice is problematic in various points (31). When personal information of patients is used, security protection of information and management of data are necessary. Liability is an issue in AI-based judgment. For instance, in rare diseases with little training data for AI or some diseases that are difficult to diagnose, the accuracy of AI-based judgment is uncertain. It is also unclear who would be held responsible if the use of AI causes harm to patients (32).

Teledentistry is being considered not only in rural areas but also in urban areas (33). For instance, teledentistry has been shown to benefit from improved efficiency in oral health service delivery in urban areas where more resources exist in proximity (33). A synchronous data-sharing system may be more beneficial in terms of efficiency. On the other hand, as older people and children generally have difficulty operating the complex systems of teledentistry on their own, easy systems and supports for use are necessary for it, which is a common issue in both rural and urban areas. Due to the insufficiency of a suitable environment, the barriers to internet connections or use of recent high-performance devices might become clear in rural areas relative to urban areas. We would like to address the need for more research to clarify the similarities and differences in teledentistry between both areas as well as implementation of teledentistry in the rural-urban partnership for mitigating the rural-urban gap of dental care.

Several limitations associated with this review warrant mention. The number of identified studies was small at 13, 5 studies had a sample size of ≤100, and only 1 was a dedicated-level randomized control trial (20). More studies with a larger sample size and high-quality designs are necessary to define the applicability and effectiveness of teledentistry. The systems and evaluation methods used in the studies were not consistent. Also, the terminology and definition of rural areas are left to each study in this review. The relationship between the degree of rurality and significance of teledentistry will be the next topic.

Conclusions

This review demonstrates the current status and potential of teledentistry in rural areas. In particular, the studies most frequently identified were for pathological diagnoses and dental screening (checkups), along with oral health support and referrals to specialists. The findings imply the worldwide need, as well as the diverse and useful application of teledentistry in rural areas. The spread of teledentistry may help healthcare systems for dental care in rural areas and mitigate the rural-urban gap in care. The future advancement of photography, AI, and communication technology can contribute to the increased accuracy of diagnoses and convenience of practice. To enhance the ease of use of the systems, as well as to establish the legal and ethical rules are also needed to apply teledentistry. Further research is expected to promote it.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-28/rc

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-28/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-28/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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