Mohamed Estai (PhD Candidate, UWA)

The Efficacy of Mobile Teledentistry in Dental

Screening

The Problem Despite progress in oral health in the past

decades, healthcare disparities do exist (1).

The majority of marginalized populations

have poorer oral health (2).

Caries is the second most costly diet-related

disease.

In 2013-14, the total expenditure on dental

care increased to $9 billion (3).

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A map of Australia with each private

dental practice (RED DOT) highlighted

Dentistry faces labour issues, particularly

maldistribution of dental labour (4).

Private sector remains the primary dental

care delivery system in Australia (4).

Regular screening can prevent or halt the

progress of caries.

Despite direct visual examination remains

the primary screening technique, this

method has limitations.

The Problem

Visual Dental Screening

DSLR camera is a better device in terms of

image quality. However, its relatively large

size and weight make it less convenient.

Intraoral camera often produces poor image

quality.

Smartphone camera is readily accessible,

provides satisfactory images and enables users

to store and share data.

Potential Solution

Intraoral Camera

Smartphone Camera

DSLR Camera

Potential Solution Mobile teledentistry refers to the

integration of cellular technology and

store-and-forward into oral care.

The introduction of smartphone into

tele-audiology and teledermatology

has proven beneficial (5,6).

However, research evidence on the

use of smartphone in dental research

is rare.

Smartphone

Cloud Storage

Reviewing

centre

Dental screening

Mobile Teledentistry

Aim & ObjectivesAim:

To evaluate the efficacy of teledentistry

approach to screen for dental caries.

Objectives:

To determine the diagnostic accuracy of

teledentistry approach to caries detection

compared to the visual examination.

To determine the diagnostic reliability of

teledentistry approach to caries detection

compared to the visual examination.

Store-and-Forward

Teledentistry

Smartphone

Screening/

DiagnosisConsultation

System Architecture A telehealth system “Remote-i”, based

on store-and-forward, was developed by

AEHRC, to work as a platform for data

storage and management.

An image acquisition android App

“Teledental” developed to facilitate

capturing photos and transmitting data to

the server (7).

A patient’s

Record

Patient records stored

in Remote-i server

1 2

3 4

Project Workflow Teledentistry approach to dental

screening involves acquiring photos from

participants’ mouths using a smartphone

camera.

Patient information and dental photos

were transmitted from the android App to

the Remote-i, for later scoring by a

screener (7).

An off-site dental practitioner access the

database from his/her desktop to assess

records and prepare treatment plan.

Participants at

the remote site

Dental expert

at the hub site

Cloud Storage “Remote-i”

One hundred regularly attending

patients at a dental clinic enrolled in this

study.

Each participant received visual

examination by a dentist to record caries

according to WHO protocol (8).

In a separate room, photos of

participant’s teeth (5 photos/patient)

were obtained using smartphone

camera.

Screening ProceduresTraditional Visual Screening

Teledental Screening

Reviewing of dental photos was conducted

by two dental practitioners (screeners).

Screeners access the database to review

dental photos and record findings on a pre-

defined chart.

These assessments form the database

which was compared to the benchmark

visual assessment.

Outcome MeasuresReviewing of records

by a dental expert

Patient’s

Record

Results Mean sensitivity for the photographic

assessment (by two screeners) as

compared to the visual screening was

61%.

Inter-examiner agreement between two

screening methods (photographic and

visual), ranging from moderate to

substantial (Kappa = 0.57 - 0.61).

Intra-examiner agreement for the

photographic assessment was almost

perfect, with Kappa = 0.89.

Benchmark = Visual dental screening

Screeners = Offsite practitioners who assess dental photographs

Benchmark Vs.

Screener 1

Benchmark Vs.

Screener 2

Sensitivity 62% 60%

Specificity 97% 98%

Kappa (95% CI) 0.57 (0.48-0.66) 0.61 (0.52-0.70)

Limitations In some cases, there was poor image quality

or unclear oral anatomy.

Up to 15% of the screened teeth were not

amenable to be scored.

Such shortcomings could contribute to the

suboptimal sensitivity and specificity.

Dark Overbright

Hazy

Perfect

An example of images with poor quality

Unclear Anatomy

Conclusions Teledentistry has the potential to detect

caries from photographs with an

acceptable diagnostic level, compared

to the direct visual screening.

Further cost-analysis research is

required to determine whether

teledentistry can reduce costs,

compared to the traditional screening.

Teledentistry

Store-and-forward

Mouth View

Teeth view

Screening tool

smartphone

Teledental Screening

Implications Perform screening to identify high-risk

groups and provide a treatment pathway for

those who require urgent intervention.

Teachers, parents or caregivers obtain

photographs from children for a dental expert

to assess at distance.

A low-cost mid-level practitioners can be

employed to perform teledental screening and

prepare treatment plan.

Remote Town

Reviewing of

records by a dentist

References1. Mejia G, Amarasena N, Ha DH, Roberts-Thomson K, Ellershaw A. Child Dental Health Survey Australia 2007: 30-year trends in child oral health.

Canbera AIHW;2012.

2. Kilpatrick N, Neumann A, Lucas N, Chapman J, Nicholson J. Oral health inequalities in a national sample of Australian children aged 2–3 and 6-7

years. Australian dental journal. 2012;57(1):38-44.

3. Australian Institute of Health and Welfare. Health expenditure Australia 2013–14. Health and welfare expenditure series no. 54. Cat. no. HWE 63.

Canberra: AIHW; 2015.

4. Australian Institute of Health and Welfare. Dental workforce 2012. National Health Workforce Series No. 7. Cat no. HWL 53. Canbera: AIHW,

2014.

5. Kroemer S, Frühauf J, Campbell T, et al. Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic

image tele‐evaluation using cellular phones. British Journal of Dermatology. 2011;164(5):973-979.

6. Mahomed-Asmail F, Eikelboom RH, Myburgh HC, Hall Iii J. Clinical validity of hearScreen™ smartphone hearing screening for school children.

Ear and hearing. 2016;37(1):e11-e17.

7. Estai M, Kanagasingam Y, Xiao D, Vignarajan J, Huang B, Kruger E, et al. A proof-of-concept evaluation of a cloud-based store-and-forward

telemedicine app for screening for oral diseases. J Telemed Telecare 2015;pii:1357633X15604554.

8. World Health Organization. Oral health surveys: basic methods, 5th ed. Geneva: World Health Organization, 2013.

Thank You