Teledentistry during COVID-19 pandemic: scientometric and content analysis approach

Covid-19 has posed significant challenges for dentists and patients, because direct patient-dentist contact and close proximity to patient’s oropharynx increase the risk of virus infection [1]. During Covid-19 pandemic, people have been reluctant to visit dentists due to the fear of infection, and front-line health care workers such as dentists have suffered from severe turmoil, anxiety, poor sleep quality, and increased risk of mental illness [2]. Regulatory agencies have recommended social distancing and home quarantine to prevent close contact between individuals and reduce the spread of infection [3]. The Italian scientific dental association has provided recommendations for the management and triage of patients before and after dental treatment, and acknowledged that by suspending dental care, the number of patients in need of hospitalization may increase in the future, so dentists can only provide emergency services and in other cases, they can treat patients digitally using tools such as telemedicine to ensure patient safety, minimize frequent contact with patient and cut the Covid-19 transmission chain [4].

Cook, for the first time in 1997, described teledentistry as the use of videoconferencing in remote diagnosis and counseling [5]. Teledentistry, also called e-dentistry [6], now encompasses the use of electronic patient records, video, and 3D digital images for diagnosis and consultation and is not limited to videoconferencing [7]. Teledentistry has, therefore, been considered as a key strategy for managing people’s health while maintaining a safe distance and limiting close contact with them. Teledentistry includes remote diagnosis, remote monitoring, remote treatment, and remote rehabilitation through virtual platform technology [3]. Telemedicine services, including teledentistry, have grown globally as public awareness has grown with a forecast of 20% further growth over the next 5 years, and revenue growth from $38 billion in 2018 to about $130 billion by 2025 in USA [8]. In a study by Vanka and colleagues, the reasons for using technology in dental services included: reducing the risk of Covid-19, communicating properly with a dentist during the pandemic, having access to dental care more quickly, and saving patient’s time and money [1].

According to Singer and colleagues, emergency dental problems and surgeries cannot be controlled through telemedicine and during the pandemic, structural changes in dental offices and clinics are necessary to reduce virus transmission between dentists and patients [4]. In Crawford and Taylor’s study of barriers to remote dental practice prior to Covid-19 epidemic, factors such as forensic concerns, dentists’ lack of confidence in using computers and online systems, software and training processes, crowded clinics, satisfaction with current system, costs of installing necessary systems and technologies, dentists’ referral fees, impossibility to perform practical interventions remotely, patient safety and data protection were among the main concerns of dentists [6].

Consequently, Covid-19 pandemic has been one of the biggest challenges of health care systems and has forced health care organizations to rapidly change their patient care approaches [9]. Therefore, the present study aimed to investigate the teledentistry services offered by dentists around the world during Covid-19 and to learn from their experiences through scientometric analysis approach. Scientometric approach utilizes quantitative analysis methods and software programs [10] to evaluate the scientific publications of researchers and scientific organizations. It also evaluates topics, journals or countries to compare and rank them for showing an overview of scientific performances and helps policy makers [11, 12].

In this study, a structured and comprehensive search was conducted in the international electronic database of Web of Sciences (WOS), using keywords such as Covid-19, Telemedicine, Teledentistry and other synonymous words extracted from the MeSH. The search strategy and number of results are presented in Table 1. In total, 94 articles were extracted from WOS database that had been published as of January 1st, 2020 to January 25th, 2022 in English language. First, the title and abstract of the articles were reviewed based on inclusion criteria;, namely, all types of studies conducted on teledentistry during Covid-19 pandemic as clinical trial, cohort and prospective studies. Systematic review articles, reviews and letters to editor were excluded from the study. After screening the title and abstract of the articles, 51 articles were selected for the full text review based on the inclusion and exclusion criteria, and finally 15 articles were included in the study. The reasons for removing articles are listed in Fig. 1. Finally, after retrieving the articles, the scientometric analysis of selected articles was carried out in terms of the most producing country, the cooperation network of these countries, the number of citations of articles in different countries, partner institutions in the production of these articles, co-authors network, journals along with the number of articles and citations, impact factor and quarter, the co-occurrence use of all keywords in the 15 articles included in the present study, and the relationship between authors, institutions and countries.

Then, the results of scientometric analysis were presented in the form of statistical tables (number, frequency, percentage) and data visualization. Then, the contents of 15 articles related to the purpose of this study were analyzed and the information were divided into 8 columns containing title of included articles, citations of each article, centers providing teledentistry services, teledentistry services, software/ app used, advantages of teledentistry, disadvantages of teledentistry and barriers/risks of teledentistry.

The scientometric analysis of articles used in this study, which were related to teledentistry during Covid-19 pandemic, showed factors such as the countries producing most articles in this field, the cooperation network of these countries, the number of citations of articles in different countries, partner institutions that helped to produce these articles, the co-authorship network, the journals along with the number of articles and citations, the impact factor and quarter of articles, the co-occurrence of all keywords in the articles and the keywords assigned by the WOS database, as well as the relationship between authors, institutions and countries. The results of this study indicated that several efforts have been made by different countries to study teledentistry during Covid-19 pandemic.

Most of the articles were conducted in England and most citations belong to the articles from China. Furthermore, “Journal of Dental Sciences” with the highest impact factor (6.116) had only 4 citations and two journals, with IF around 3, had the most citations (more than 40 citations). This indicates that impact factor might not be an important element to cite a journal’s articles. The number of included articles in short timespan was not high. So all of the authors in these articles participated and collaborated in one article so we can find out the more active authors in the field.

In addition to scientometric analysis of included articles for realizing the overview of the production in the field, the content of these articles was also analyzed. Teledentistry has been made possible through Information Technology (IT), internet, patient’s online electronic record, digital devices such intraoral cameras, webcams, and remote computer monitors [25]. Remote assessment of dentists should be done when they feel that they can complete a treatment after performing adequate evaluation. Remote prescribing should be clinically justified [15]. Using technologies such as interactive live examination, video and specialized chartrooms between dentists, distance patient education, tele-triage, tele-monitoring and treatment of oral lesions, tele-consultation between dentists, etc. reduce the risk of Covid-19 infection [25]. Sharma and colleagues have divided the applications of pediatric teledentistry into three general categories of education and promotion of oral health, remote diagnosis and monitoring, and behavioral guidance [25].

In addition to reducing the cost of travel, teledentistry can reduce the anxiety of people with dental phobia, prioritize patients, reject inappropriate referrals without face-to-face consultation, increase the range of services in the field of oral health, and give parents the opportunity to choose pre-appointment treatment options [4, 6, 15, 22]. Also, during Covid-19 pandemic, teledentistry can be used as a suitable alternative for patients who do not need immediate face-to-face examination [8, 15]. It also prevents the accumulation of patients in the office, which reduces the spread of infection [8, 14, 19, 26].

Giudice and colleagues, used WhatsApp for remote consultation and follow-up of patients. They also stated that, remote consultation and constant monitoring of patient improve patient’s participation and adaptation to treatment, as well as physician-patient relationship [21, 24]. Prior to Covid-19 pandemic, teledentistry services may have been difficult to provide but it has become easier for dentists and patients to accept such services [8]. Subhan and colleagues in their study stated that dental specialists in Pakistan before Covid-19 pandemic did not have enough knowledge about teledentistry but now their knowledge about the advantages of teledentistry and its implementation has been significantly increased [27].

In a qualitative study conducted by Plessas and colleagues during Covid-19 pandemic, the dentists stated that they felt good about helping patients, reducing their pain and suffering, the professional satisfaction of doing the right thing. Also, factors such as strategic team working, collective coping strategies, effective organizational care, the ability to help, and the sense of pride have created a positive experience in them [2]. In contrast, feelings of frustration due to scattered communication, feelings of injustice in communication, high demand of patients, complex decisions, uncertainty about safety, inefficient communication channels, lack of commitment to remote video consulting, the quality of referrals, communication with other health care providers, slow communication, poor support, high workload without extra payment, change in prescribing behavior, irreversible decisions, out-of-date computer systems, perceptions of patient ability in interaction, and lack of radiography have been mentioned as the negative points of teledentistry [2, 8, 9, 15, 23, 24].

However, the main concern with teledentistry might be attributed to the misdiagnosis and mismanagement of patient due to the following factors: the quality of received images and radiographies, sense and degree of patient cooperation, the quality of IT devices belonging to dentists and patients, lack of access to medical history, systemic diseases of the patient which may harm the patient, and medical and legal issues [15, 20, 26]. Accuracy of diagnosis depends on using the same and professional standards, the quality of radiographic images, quality of video calls, microphone resolution, good quality internet patient cooperation and quality of electronic devices [6, 7, 9, 15, 17, 19, 24]. These factors are influenced by the socio-economic status of patient and the level of patient’s knowledge about IT [7]. Al-Shaya and colleagues in their study acknowledged that teledentistry with the mobile phone photo is not as accurate as clinical examination through radiography but the initial diagnosis of caries in children with teledentistry has acceptable reliability [28].

Clinical examination and remote screening of patients, for example through WhatsApp images, can be a suitable, reliable and cost-effective tool in a low-resource environment [22, 29, 30]. Barriers to teledentistry include patients’ lack of knowledge about IT, poor and inadequate IT literacy of dentists, unfamiliarity of dentists and patients with technology, limitations in infrastructure (such as poor internet access, lack of hardware, cost and efficiency of equipment), low video quality, audio-video mismatch that can be replaced by direct communication (simultaneous communication), how to store, send and share patient information, confidentiality and protection of patient information, organizational changes in accepting teledentistry, non-acceptance of teledentistry services by relevant authorities including insurance companies, lack of transparency in reimbursement, non-cooperation of other medical centers, inadequate circulars, cost of installing teledentistry equipment and resistance of dentists to new technologies [3, 9, 19, 20, 22, 24, 25, 31].

The field of dentistry also needs a fundamental review and rapid and planned changes to provide teledentistry services to vulnerable populations such as children, elderly, people with special needs and people with low socio-economic status. Therefore, this development requires systematic planning, analysis and feasibility studies, so further studies should be conducted to improve its efficiency [32]. As a consequence, educating dentists about the use of technology, obtaining informed consent from patients before starting any treatment, conducting further research on the improving the effectiveness of teledentistry in different dental clinics, examining the cost-effectiveness of procedures, assessment of patient satisfaction, long-term socioeconomic, psychological, and physical effects of teledentistry services, development of, reliable and effective software for patient management, optimization of software and procedures and considering taxes, obtaining licenses, new business models, developing guidelines and clear rules for reimbursement of services, violations and forensics are among the solutions to overcome these challenges [6, 9, 13, 18, 20, 21, 23, 25].

Considering that teledentistry is more compatible with providing innovative solutions to problems, while limiting the exposure of dentists and patients to Covid-19 [8], further studies are needed to probe into the similarities and differences of teledentistry services in different geographical areas, particularly in developing countries in order to take strategic steps towards addressing the existing and forthcoming challenges while taking advantage of teledentistry [15] because, as shown in Figs. 2 and 3, a few of developing countries collaborated to produce documents in the field of teledentistry during COVID-19. However, this topic seems to be important and useful in all countries including developing countries.

With the outbreak of Covid-19, health care organizations have faced a sudden increase in demand for the use of IT in health care. Teledentistry, not only during Covid-19 pandemic, but also under normal circumstances can be a useful and complementary tool for face-to-face assessment of patients before treatment, patient education and monitoring, preventive care, post-treatment follow-up, diagnosis of diseases and treatment planning, which reduce anxiety in patients and lead to improved outcomes of patient management. Achieving this goal requires the cooperation of Ministry of Health and Medical Education, insurance organizations, heads of hospitals and clinics and other relevant authorities. Some of the strengths of this study include the review of articles in the most authoritative database, and scientometric analysis of selected articles. In regard to the weaknesses of this study, we can refer to the lack of review of other databases.

The results of present study showed the numerous efforts have been made by different countries to study teledentistry during Covid-19 pandemic. Teledentistry through IT has facilitated live and interactive examination of patients, videoconferencing, distance education of patient, tele-triage, tele-monitoring of treatment process, and tele-consultation, which have ultimately increased client satisfaction. Teledentistry, in addition to reducing the cost of travel, reduces the anxiety of people with dental phobias by increasing the range of services in the field of oral health care. During Covid-19 epidemic, teledentistry has been a viable alternative for patients who do not need immediate and face-to-face oral assessment. By the use of teledentistry during the pandemic, dentists will able to provide dental care and reduce the chain of infection. In contrast, uncertainty about safety, inefficient communication channels, lack of commitment to video conferencing, and barriers to large-scale implementation of this technology have been mentioned as some of the barriers to teledentistry. The field of teledentistry requires a fundamental review, and rapid and planned changes to facilitate the provision of teledentistry services. Considering that teledentistry is effective in limiting the exposure of dentists and patients to Covid-19, more and in-depth studies are required in developing countries to address the existing and forthcoming challenges of teledentistry, while taking advantage of this new approach.