The Efficacy of Mobile Teledentistry in Dental Screening. Mohamed Estai (PhD Candidate, UWA)

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1 The Efficacy of Mobile Teledentistry in Dental Screening Mohamed Estai (PhD Candidate, UWA)

2 Number of decayed teeth The Problem 12 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 , the total expenditure on dental care increased to $9 billion (3)

3 The Problem 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. A map of Australia with each private dental practice (RED DOT) highlighted Despite direct visual examination remains the primary screening technique, this method has limitations. Visual Dental Screening

4 Potential Solution DSLR Camera 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. Intraoral Camera Smartphone Camera

5 Potential Solution Mobile teledentistry refers to the integration of cellular technology and store-and-forward into oral care. Mobile Teledentistry Reviewing centre 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. Cloud Storage Smartphone Dental screening

6 Aim & Objectives Aim: 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. Smartphone Store-and- Forward Teledentistry To determine the diagnostic reliability of teledentistry approach to caries detection compared to the visual examination. Consultation Screening/ Diagnosis

7 System Architecture 1 2 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). Patient records stored in Remote-i server A patient s Record 3 4

8 Project Workflow Cloud Storage Remote-i 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

9 Screening Procedures One hundred regularly attending patients at a dental clinic enrolled in this study. Teledental Screening Traditional Visual Screening 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.

10 Outcome Measures Reviewing of records by a dental expert Reviewing of dental photos was conducted by two dental practitioners (screeners). Screeners access the database to review dental photos and record findings on a predefined chart. Patient s Record These assessments form the database which was compared to the benchmark visual assessment.

11 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 = ). Benchmark Vs. Screener 1 Benchmark Vs. Screener 2 Sensitivity 62% 60% Specificity 97% 98% Kappa (95% CI) 0.57 ( ) 0.61 ( ) Benchmark = Visual dental screening Screeners = Offsite practitioners who assess dental photographs Intra-examiner agreement for the photographic assessment was almost perfect, with Kappa = 0.89.

12 Limitations An example of images with poor quality 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 Hazy Overbright Unclear Anatomy Perfect

13 Conclusions Teledentistry has the potential to detect caries from photographs with an acceptable diagnostic level, compared to the direct visual screening. Mouth View Teledental Screening Teeth view Further cost-analysis research is required to determine whether teledentistry can reduce costs, compared to the traditional screening. Teledentistry Store-and-forward Screening tool smartphone

14 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. Remote Town Reviewing of records by a dentist A low-cost mid-level practitioners can be employed to perform teledental screening and prepare treatment plan.

15 References 1. 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; 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): Australian Institute of Health and Welfare. Health expenditure Australia Health and welfare expenditure series no. 54. Cat. no. HWE 63. Canberra: AIHW; Australian Institute of Health and Welfare. Dental workforce National Health Workforce Series No. 7. Cat no. HWL 53. Canbera: AIHW, 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): 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-e 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: X World Health Organization. Oral health surveys: basic methods, 5th ed. Geneva: World Health Organization, 2013.

16 Thank You