Tele-dentistry, its trends, scope, and future framework in oral medicine; a scoping review during January 1999 to December 2021

The main research question was “how to determine the benefits, potential applications and a framework of applying tele-dentistry in oral medicine?”. Four key objectives then were defined as follows:

A research question of a scoping review should cover the population, the concept, and the context (PCC). Here, according to the research question, the population was defined as all the publications which consider tele-dentistry in the field of oral medicine. The concept included all the facilitators and barriers which help applying tele-dentistry in oral medicine or restricting the usage as well as the participants` views. And the context contained all the technical, infrastructural, clinical, and organizational factors related to the clinics and dentistry hospitals which apply tele-dentistry in oral medicine.

In this step, keywords for the scoping review were selected following a preliminary review of the literature. We have searched four databases including ISI web of science, PubMed, Scopus, and ProQuest. The search duration was defined from January 1999 to December 2021. We selected 1999 as an initial year based on the results of a published systematic review [6]. Another reason for choosing this year to limit the search was that the most important and relevant field of study was retrieved in 1999. The inclusion criteria were all original articles, non-original articles consisting of reviews, editorials, letters, commentaries and book chapters, and dissertations. Moreover, all full-text of papers were in English-language. Systematic reviews and studies about remote screening routines in dentistry, teledentistry in oral radiology and tele-dentistry in oral and maxillofacial surgery were excluded. The logical operators, “OR” and “AND,” were used to increase the search sensitivity. The study keywords were chosen as a result of a preliminary review of the literature. The selected keywords, based on their relevant Medical Subject Headings (MeSH), have been searched in various databases. EndNote reference manager X8.1 (Clarivate Analytics, Philadelphia, PA, USA) was used to manage the retrieved reference and find duplicate references. Table1- Appendix shows the finalized search strategy of the scoping review.

After confirming the search strategy, the achieved articles via the systematic search of the four mentioned databases were reviewed first by the title and abstract and then by their full texts. All the process was conducted by two of the researchers separately and independently (FN and PB. Additional records from other sources were also searched through Google Scholar to complete the search,

For assuring the eligibility of the included full-texts, another researcher (MM) screened the full-text of the studies based on PCC, the review`s research question and objectives (RQ) and the inclusion and exclusion criteria. Figure 1 illustrates PRISMA Flow Diagram for the scoping review process [31], a narrative description of the search decision process along with the search decision flowchart.

After selecting the final studies based on the desired inclusion and exclusion criteria, data related to the field of tele-dentistry in oral medicine were extracted and included in data extraction forms applying Microsoft Excel₂₀₁₆. The first author’s name, country of origin, year of publication, aim and type of the study, study setting, study population, methodology, main findings, and implications were extracted and charted in the data extraction form. This charting process were implemented simultaneously and jointly by two of the research team`s members (FN and PB) [30]. The chart distinctly shows the characteristics of the included studies according to the data of the extraction form (Table2- Appendix).

At this step, two researchers (FN and PB) independently integrated and summarized the texts to answer the study question. To categorize and summarize the data, the thematic analysis was used via the following steps [32]:

Excel₂₀₁₆ was used for descriptive quantitative analysis and MAXQDA version 10 was applied for qualitative thematic analysis. MAXQDA is a data analysis software which can be used for content analysis. For this purpose, the meaningful units extracted from the included articles were imported from Excel to "Document System" component of the MAXQDA software. Then, by using the component "Document Browser", a section of the text was dedicated to the code via selecting the function of "Code with new code" from the context menu. A dialogue box has been opened to define new codes in the top row of which a code name has been entered. Afterwards, the code categorization process was carried out by assigning categories.

To be sure of the rigorous and trustworthiness [33] of the findings and the appropriate description of the thematic map, the final tabulated themes synthesized from the included articles accompanied with the initial thematic map determined by the research team were discussed in a virtual mini expert panel including four well experienced and knowledgeable participants in digital health in dentistry.

A final selection of 59 studies were included in the scoping review. Figure 1 illustrates PRISMA Flow Diagram for the scoping review process. Out of 59 articles, 23(38.98%) articles were published in 2021. Table 2-Appendix shows the characteristics of these articles. Also, 27 (46%) out of 59 publications have addressed the various applications of tele-dentistry during COVID-19 pandemic in the field of oral medicine. From geographical distribution perspective, most of the papers were published in Brazil (n = 13)/22.03%, India (n = 7)/11.86%, USA(n = 6)/10.17%, UK (n = 5)/8.47% and France (n = 5)/8.47%. Figure 2 illustrates the distribution of the included articles according to their country.

Other descriptive results show that there are seven categories of different types of tele-dentistry applications. Figures 3 illustrates that tele-consultation and tele-diagnosis were used more than others. In particular, teleconsultation has been used more between 2020–2021. In addition, tele-consultation was applied to manage patients with oral medicine conditions, oral medicine referrals, assess, and follow up of patient, and education. Furthermore, the focus on the concepts of tele-triage, remote screening, tele-visit and telemonitoring has increased over the past two years (Fig. 3).

The results of the thematic analysis are divided in three following sections: facilitators and barriers of applying tele-dentistry in oral medicine, Participants’ view and developing the framework.

Facilitators of tele-dentistry were categorized into seven themes, including information, skill, human resource, technical, administrative, financial, and training and education. Table 1 tabulates these seven facilitators accompanied with their sub-facilitators, item indications and descriptions.

Similarly, the barriers in applying tele-dentistry in the field of oral medicine are tabulated in Table 1. These barriers have been classified into six domains individual and environmental, organizational, regulation, clinical, and technical barriers. As Table 1 implies most of these barriers are explored in the categories of individual barriers from the patients` side and the technical barriers of applying tele-dentistry in oral medicine. Additional explanations regarding barriers are also described in Appendix 2.

Two main concepts of satisfaction and perceived usefulness of the technology were analyzed from the participants’ view.

According to the thematic analysis of the included literature, participants who apply tele-dentistry services in the field of oral medicine include healthcare providers, healthcare systems and healthcare seekers. These participants clarify some reasons for satisfaction with their experiences of applying tele-dentistry, such as access to care during the COVID-19 pandemic [15, 56], providing oral medicine services in rural areas [15], communication between patients and doctors [15], the usability of tele-dentistry services [15, 57], quality in data communication [25], high-quality internet connection [40], and high-quality digital images with medical and dental information to facilitate diagnosis of oral mucosal disease [25]. They also provide some reasons for dissatisfaction with their experience in applying tele-dentistry, for example inadequate information [35], Lack of physical examination by a doctor [15] and not being involved in the care and treatment process during the consultation as much as they wanted [35].

From the aspect of usefulness perceived on tele-dentistry services by the participants, as Table 2 demonstrates, 14 domains are explored including time, access to oral medicine services, communication between dental clinicians, referrals, triage, travel, cost, education and training, health crisis, surveillance, quality of care, patient management and monitoring, and patient empowerment. Each of these domains include some implications that are synthesized and reported as items in Table 2.

The framework developed according to the main themes and using a general system model that includes input, process, and output. In other words, the results were modelled using a simple system analysis model known as IPO (input- process-output) [64].The need for applying tele-dentistry services and usefulness perceived or advantages of the tele-dentistry services by the users serve as input. In the process of using tele-dentistry services, there are some barriers and facilitators which could influence the process and ultimately the outputs. Outputs or outcomes such as user satisfaction and perceived usefulness are linked to feedback and used as a starting point for tele-dentistry services. In addition, according to participants’ view, these services were found to be useful in 14 domains and satisfactory, which has been affected by the application of facilitators. At the same time, negative outcomes such as dissatisfaction with services are emerging because of the probable barriers and limitations (Fig. 4).

According to the present thematic results, tele-dentistry facilitators were classified into seven groups. Most of the studies have concentrated on technical, informational and skill facilitators, respectively. In terms of technical facilitators, one of the infrastructures needed to implement tele-dentistry services is the technical aspect [66]. Using of social networks as a facilitator stem from their benefits. To illustrate, WhatsApp and similar applications are one of the strategies to facilitate daily patient-provider interactions and to accelerate clinical communication between oral health professionals [65]. In addition, their capabilities such as photo sharing, video chat, and messaging can be used in various aspects including screening, consultation, visits, and diagnosis [13, 20, 44, 65]. Furthermore, user access to technology has been one of the main facilitators identified in the studies. Indeed, elements such as using economical [12, 20, 34, 63] and user-friendly [26, 45] technologies and high level of mobile and internet penetration [11, 34] play a significant role in people`s access to tele-dentistry services. In terms of using affordable technologies as a facilitator, one of the telemedicine projects` objectives is to enhance access to health services for remote populations, particularly in tele-dentistry [7, 23, 24]. These technologies apply to support healthcare providers and patients in this area [10, 24, 27]. Another aspect that makes the use of affordable technologies an important consideration is that there are inequalities in the delivery of oral health services [67]. It appears that one of the useful means of reducing inequities is tele-dentistry applications with an emphasis on using technologies that increase user access to services.

Several studies have underlined the effective role of data quality in the diagnosis [9, 24], consultation [5, 24], and prioritization of patients in emergency conditions [19, 25] and documentation [5]. In addition, quality data includes features such as accuracy, timeliness, completeness, relevance, consistency, reliability and validity, and the presentation of data [68, 69]. This information is critical in supporting the diagnosis, treatment and measurement of the quality of patient care and improving and facilitating reimbursement [70].

Regarding the digital skills of patients and healthcare providers, studies have shown that the more skilled people use the technology, the more they will want to use it [11]. Communication skills, accurate documentation, and clinical experience are also considered as effective factors to optimize patient visit times, provide reliable diagnostics, and implement tele-consultation services in particular [5, 7, 11, 25].

The results showed that the barriers of tele-dentistry services were divided into six groups. Of these groups, more studies focused on technical and individual barriers.

In terms of technical barriers, most of the studies have concentrated on bandwidth problems and photo quality problems. Bandwidth problems have been raised in remote and rural areas, especially for oral cancer screening services that focus on underserved populations [1, 23, 24]. In tele-dentistry, image quality is an important factor in the correct diagnosis of oral disease [24, 26]. In this regard, to improve the quality of images, facilitators such as educating the patient for photography, providing guidelines for oral photography and using appropriate tools for photography were used [11, 39].

As for individual barriers, such as behavioral barriers and Lack of experience and skill has been addressed through some studies. For example, the lack of digital literacy is followed by the difficulty of using tele-dentistry services. So, it seems that education improvement as well as the use of user-friendly and convenient technologies is one way to mitigate that problem. Also, the difficulty of taking pictures of oral cavity in good light using a mobile phone led to a decrease in their willingness to use these technologies [11, 21]. Therefore, one of the ways to increase the patient's interest in tele-dentistry is to provide educational videos for taking photographs [11]. In addition, human errors and low-quality information are classified as personal and technical barriers, respectively. It appears that the use of artificial intelligence (AI) to adjust these factors could be an appropriate solution. In fact, AI provides enhanced remote screening, diagnosis, record keeping, triage, and monitoring of dental patients with smart tools [71]. AI can help dentists make critical and time-critical decisions. It can eliminate the human element of error in decision-making, providing a consistently high quality of healthcare [72].

The results show that the perceived usefulness of tele-dentistry services in oral medicine was classified by users into 14 categories. Most of the studies have been conducted in the field of access to oral services. A study showed that for oral mucosal lesions, access to services has been improved in a timely and safe manner, while providing the opportunity to assess the patient's condition for pain relief, bleeding, and other postoperative complications using tele-dentistry [51]. This is also supported by another study, which suggests that tele-dentistry could improve access to services for people who are receiving cancer treatment. In this way, the side effects of patients can be followed by oral specialists using tele-dentistry [18]. As for continuity of clinical care, the results of a study demonstrated that patients were happy to continue their clinical care in unusual circumstances [5].

In terms of reasons for tele-dentistry services` dissatisfaction, lack of physical examination of the patient by doctors [10, 11, 20] is one of the problems that has received greater attention than others and has been raised by several studies. In a study which examined the patient's point of view and experience, the lack of physical examination was one of the barriers in the tele-dentistry, this case is not as serious in patients as in cases such as the difficulty of oral photography and the use of computer services [11]. In another study, it was reported that limiting physical exams was one of the problems in the investigation of patient experience, nevertheless, they had positive views on tele-dentistry [35]. Also, one study indicated that one of the greatest disadvantages of remote dentistry is the lack of physical examination [53]. This seems to have been compensated this problem with the use of high-quality photos. However, several studies have shown that face-to-face examination are the gold standard.

Studies have indicated the application of tele-dentistry dentistry in the COVID-19 crisis. In several studies tele-dentistry as an approach for facilitating access to oral medicine services during the COVID-19 pandemic for people with oral medicine conditions, which is in line with infection control protocols [22, 41, 62]. It is also important to follow up and provide advice to patients with oral medicine conditions, and some studies have indicated that this was one of the benefits of tele-dentistry during COVID-19 [12, 46]. In addition, one of the major issues addressed during the covid-19 and pandemic quarantine was the lack of unnecessary hospitalization, which was important in both directions to prevent the spread of the virus and to account for the high workload associated with COVID-19. In fact, tele-dentistry services have reduced unnecessary hospital referrals and saved resources by providing services for those with oral medicine problems [17, 63].

The review of selected studies has revealed several limitations that researchers can consider in their future research. The small sample size was suggested by numerous studies [3, 8, 15, 25, 40, 61, 62, 65, 73], Diagnostic error is also another limitation raised by studies, the reasons for which can be choosing histopathology as the standard gold [24], as well as the lack of oral examination due to the selection of new people [39]. One way to deal with this issue is to use tele-dentistry for patients` follow-up who have been examined on a face-to-face visit [39]. Also, other limitation including not comparing the provisional diagnosis of photography with the provisional diagnosis at in-person appointment for same patient [25], Possibility in remembering of diagnosis during clinical oral examination when reviewing the images taken using the mobile phone after weeks of washing out period [26], Limitations in diagnosis relying solely on visual examination [25], and Influencing of spectrum of lesions on the concordance values [26].

There are several suggestions for researcher, and everyone wants to develop the tele-dentistry services in the field of oral medicine: