Challenges in the uptake of telemedicine in dentistry

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Context

Although the average dentist-to-population ratio has increased over recent decades, a significant discrepancy between the ratio in urban and rural regions still exists¹. With the availability of oral care services very unevenly distributed in regional and remote/very remote areas, underserved people seek oral care from non-dental care providers, most commonly physicians, hospital emergency departments or pharmacies^2-4. Non-dental care providers often help to provide symptomatic relief and/or issue a referral to a dentist rather than providing effective dental care^2,3.

Short-term measures such as relying on visiting services or volunteerism to overcome the lack of dental services in underserved areas can help but are often only temporary solutions. We need to look for long-term and systematic approaches for an ongoing solution. Against this backdrop and coupled with the decreasing cost of and innovations in information and communication technology (ICT), there is growing interest in the adoption of telemedicine services⁵. Teledentistry is a form of telemedicine that is specifically dedicated to dentistry that uses electronic medical records, ICT and the internet to provide consultation at a distance⁶. It is an innovative method of health service delivery that has the potential to facilitate timely distribution of information to locally based practitioners for better decision making, effectively triage patients who require referrals and support locally based treatment^7,8. This strategy allows the underserved population to seek treatment earlier, provide access to specialist care and minimise the burdens of patients/parents who would have to travel long distances to receive consultations. The potential advantages of teledentistry are summarised in Table 1.

The history of teledentistry can be traced back to the 1990s, when the US Army established the first teledentistry project, Total Dental Access, within the Department of Defense, which enabled the referring general dentists located in a dental clinic at a military base to consult with dental specialists at a distance⁹. Ever since, the number of teledentistry projects has rapidly increased, particularly in the USA, Europe, Australia and Brazil¹⁰. Despite growing interest in this technology, there has been a relatively slow integration of telemedicine into the mainstream oral health system. This can be attributed to the fact that many teledentistry projects are still ongoing or in proof-of-concept stages¹⁰. In the past decade, the Alaskan Native Tribal Health Consortium in partnership with the University of Washington established a telemedicine-based workforce model with a long-term strategy that centres on developing and training dental health aide therapists in Alaska to provide essential dental care, utilising telemedicine, to Alaskan residents under indirect supervision by dental experts^11,12.

Two different technological approaches are used in telemedicine applications: real-time and store-and-forward technology. Although teledentistry services are still largely utilised in real time¹⁰, store-and-forward teledentistry has proven to be more cost-saving and efficient compared to real-time and in-person care approaches^4,13,14. Previous studies have not provided any evidence that telemedicine interventions are cost-effective when compared with non-telemedicine care approaches^15,16. Most research reports have indicated that the absence of evidence supporting the cost-effectiveness and effectiveness of telemedicine creates a barrier to its implementation within routine healthcare services. Cost-analysis studies of telemedicine are often pragmatic and mainly concerned with costs and their minimisation while ignoring equity issues of access to health care. Regardless of head-to-head economic benefits, evidence already indicates that telemedicine, even with its potential extra costs, can help in reducing inequalities in oral health¹⁷.

Table 1: Benefits of teledentistry

Issues

Despite its enormous potential, several constraints for the growth and acceptance of teledentistry do exist (Table 2). The successful implementation of a sustainable telemedicine model is a complex and collaborative process involving numerous factors at individual, infrastructure and organisational levels¹⁸. Although perceived usefulness and ease of use are essential factors in the acceptance of any technology¹⁹, there is very little published evidence regarding patient readiness and acceptance of teledentistry services²⁰. The body of literature on the acceptance of teledentistry is limited to care providers'^21-25 or end-users'²⁶ perceptions of this technology. Further research is needed to examine in depth the patient's acceptance of teledentistry. Other considerations such as non-technological, political or organisational barriers (planning, bureaucratic difficulties, lack of reimbursement guidelines, and medico-legal and copyright issues) have not been well investigated in the literature^27,28. Such issues may become more evident when the practice of teledentistry becomes more widespread, highlighting the need for creating new laws to regulate the practice of teledentistry.

Table 2: Barriers to the uptake of teledentistry

Lessons learned

The shortcomings in existing policy and practice may indicate that the use of teledentistry does not receive support by healthcare policy-makers due to lack of evidence related to the cost-effectiveness of teledentistry in head-to-head comparisons²⁹. Addressing the barriers that delay the implementation of teledentistry services can provide a valuable insight into its acceptance and establish an evidence base that can help to inform future decisions about the benefits of teledentistry. Both strong political support and adoption of new legislations are essential to bring the underserved population up to an acceptable level of oral health and reduce the inequalities in oral health status between those who live in rural areas and in general populations.

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