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SCIENTIFIC EVIDENCE ON TELEDENTISTRY IN DENTISTRY DIAGNOSIS
EVIDENCIAS CIENTÍFICAS EN TELEODONTOLOGÍA EN EL DIAGNÓSTICO ODONTOLÓGICO
EVIDÊNCIAS CIENTÍFICAS DA TELEODONTOLOGIA NO DIAGNÓSTICO ODONTOLÓGICO
Lara Guabiraba da Silva¹, Rafael Santiago Barroso2, Francisca Tereza Coelho Matos3, Marconi Raphael de Siqueira Rêgo4, Luana Kelle Batista Moura5
1- Centro Universitário UNINOVAFAPI. Acadêmico de Odontologia. E-mail: [email protected] 2 - Centro Universitário UNINOVAFAPI. Acadêmico de Odontologia. E-mail: [email protected] 3 - Centro Universitário UNINOVAFAPI. PhD in Endodontics. E-mail: [email protected] 4 - Centro Universitário UNINOVAFAPI. Master of Science in Health. E-mail: [email protected] 5 - Centro Universitário UNINOVAFAPI. PhD in Endodontics. E-mail: [email protected]
Francisca Tereza Coelho Matos (Corresponding author) Centro Universitário UNINOVAFAPI. E-mail: [email protected]
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Abstract Objective: The objective of the study was to analyze the scientific evidence of teleodontology in diagnosis in dentistry. Material and Methods: Integrative review based on the PICO strategy, which selected articles published in full in the English language, between 2012 and 2017, using the descriptors "telehealth", "dentistry" and "diagnostic" in the Web database of Science™. Results: A total of 464 publications were found, of which 387 were evaluated according to the inclusion and exclusion criteria. After reading the titles and summaries, only 3 articles were fit to the selection criteria. Conclusion: The scientific evidence on diagnosis in teleodontology is referenced with the use of electronic systems and telehealth applications. These new technologies add to the process of academic and professional training, with the aim of improving access to health services. Keywords: Telehealth. Dentistry. Diagnosis.
Resumen Objetivo: El objetivo del estudio fue analizar cuáles son las evidencias científicas de la teleodontología en el diagnóstico en odontología. Material y métodos:En el presente trabajo se analizaron los resultados obtenidos en el análisis de los resultados obtenidos en el análisis de los resultados obtenidos en el estudio. de ScienceTM. Resultados: Se han encontrado 464 publicaciones, de las cuales 387 fueron evaluadas según los criterios de inclusión y exclusión. Después de la lectura de los títulos y resúmenes se encuadraron solamente 3 artículos a los criterios de selección. Conclusión: Las evidencias científicas sobre el diagnóstico en teleodontología son referenciadas con uso de sistemas electrónicos y aplicaciones de telesalud. Estas nuevas tecnologías agregan en el proceso de formación académica y profesional, con el objetivo de mejorar el acceso a los servicios de salud. Descriptores: Telelaude. Odontología. Diagnóstico.
Resumo Objetivo: O objetivo do estudo foi analisar quais são as evidências científicas da teleodontologia no diagnóstico em odontologia. Material e Metodos: Revisão integrativa baseada na estratégia PICO, onde foram selecionados artigos publicados na íntegra, em língua inglesa, entre os anos de 2012 a 2017, utilizando os descritores “telehealth”, “dentistry” e “diagnostic” na base de dados Web of ScienceTM. Resultados: Foram encontradas 464 publicações, das quais 387 foram avaliadas segundo os critérios de inclusão e exclusão. Após a leitura dos títulos e resumos se enquadraram somente 3 artigos aos critérios de seleção. Conclusão: As evidências científicas sobre o diagnóstico em teleodontologia são referenciadas com uso de sistemas eletrônicos e aplicativos de telesaúde. Estas novas tecnologias agregam no processo de formação acadêmica e profissional, com intuito de melhoria do acesso aos serviços de saúde. Descritores: Telessaúde. Odontologia. Diagnóstico.
Introduction
Historically, teaching dentistry has been based on the transmission of knowledge focused on the development of technical skills, oral diseases and everyday situations related to clinical practices. Thus, it is extremely important to
129 know and evaluate the new processes of quality education and health education in dentistry, combined with economic, social and cultural development.(1) In Brazil, the requirements of the new National Curricular Guidelines (CND) have caused significant changes in dental education with the insertion of collective oral health policies, in which changes in the practice of the profession and in new jobs for professionals, especially in Health Care Networks.(1-2) Oral health care is characterized by activities of an educational and therapeutic nature, and the latter requires technological devices to guarantee the best possible diagnosis. However, many sites assisted by the Oral Health Strategy (ESB) do not have low-cost publicly available technological resources such as imaging tests, which are considered to be tools that help a great deal in the diagnosis and prognosis of diseases.(2-3) Currently, dentistry uses differentiated equipment, allowing access to important images for the planning of clinical cases, offering technical resources to obtain images of patients, which will favor the dental surgeon, allowing it to make a better diagnosis and for the visualization and understanding of the treatment by the patients.(3) However, as these equipments are not available in certain localities, the need for new technological advances to contemplate the various social aspects and to positively add to the provision of qualified assistance is evident. These advances have as central elements a set of technologies based on microelectronics, telecommunications and information technology, called Information and Communication Technologies (ICT).(4) Telehealth is defined as the use of modern (ICT) for health-related distance activities at its various levels (primary, secondary and tertiary), enabling interaction between health professionals or between them and their patients, as well as remote access to diagnostic or even therapeutic support resources through robotics.(4) Teleodontology can be conceptualized as a tool for provision of dental care, be it diagnostic, treatment or second opinion, carried out through electronic transmission between different sites, proposing its use for case screening and offering support to clinical professionals so that the treatment can be done in their places of origin without the need to refer patients to specialized services.(5) The literature emphasizes that it can be characterized as a practical and economically viable method of promoting health for underserved populations including socially disadvantaged individuals living in remote locations or rural areas who do not have access to routine dental care.(6) However, it is understood that the teaching process in the institutions is still less than expected, reflecting this paradigm in professional practice, even with the new technologies of health education that are easily accessible. With this, the objective of the present study is to analyze the scientific evidences about the diagnosis in teleodontology. Based on the objective, the following guiding question emerges: "What are the scientific evidences about teleodontology as a diagnostic tool in dentistry?".
Material and Methods
In search of the proposed objective, we selected the integrative review method, which allows us to include in the study theoretical and empirical literature, as well as studies with different methodological approaches.(7)
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Evidence-Based Practices (EBPs) are methodologies and processes for identifying evidence that a certain treatment or diagnostic environment is effective, strategies for assessing the quality of studies, and mechanisms for implementation in care. care, through the identification and promotion of practices that work and elimination of inefficient or harmful ones, and minimization of the gap between the generation of evidence and its application in patient care.(8) The PBE proposes that the clinical problems that arise in the practice of care, teaching or research, be decomposed and organized using the PICO strategy, which represents an acronym for Patient, Intervention, Comparison and outcome. Within the PBE these four components are the fundamental elements of the research question and the construction of the question for the bibliographic search of evidence. The PICO strategy can be used to construct research questions of different natures, from the clinic, human and material resources management, the search for instruments to evaluate symptoms, among others, the appropriate research questions (well constructed) in which they enable the correct definition of information (evidence) that is necessary to solve the clinical question of research, maximizing the retrieval of evidence in the databases, focusing on the scope of the research and avoiding unnecessary searches.(8) Taking into account the PICO strategy, in this work, the diagnosis of patients will be defined as "P", the "I" will be the telehealth activities, the "C" will be classified as a form of intervention and the "O" as a treatment strategy. This integrative review of the literature was carried out during August 2017 by three reviewers, structured in eight stages: 1) identification of the theme and formulation of the guiding question; 2) establishment of criteria for inclusion and exclusion of studies; 3) definition of research databases; 4) definition of bibliographic search resources; 5) definition of information to be extracted from the selected studies; 6) evaluation of included studies; 7) interpretation of results; 8) presentation of the review.(9) Considering the different possibilities and peculiarities of telecommunication in the health area, the PICO strategy was used to elaborate the guiding question. Using the tool available in the Web of ScienceTM,(10) the following question was asked: What are the scientific evidences about teleodontology as a diagnostic tool in dentistry? Inclusion criteria were studies on diagnostic methods in teleodontology published in full in the English language, in the years 2012 to 2017 and with a methodological outline that included qualitative and quantitative data, since it was sought to understand the phenomenon in an in-depth way. The exclusion criteria were restricted to studies related to other health professionals, informal case reports, book chapters, dissertations, theses, reports, news articles, editorials, non-scientific texts, duplicates and literature reviews. The search strategy was structured with the indexed descriptors (http://decs.bvs.br/.) "Telehealth", "dentistry" and "diagnostic", in which they were implemented in the Web of Science database according to the respective research resources, as shown in Table 1.
Table 1 - Search strategy and indexing of descriptors, Teresina, Brazil, 2017 Data base Research Resources
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Web of Science (telehealth – tópico – adicionar outro campo – (http://apps.webofknowledge.com) AND dentistry – tópico – adicionar outro campo – AND diagnostic – tópico - pesquisar).
Source: Direct Search, 2017.
From the results found, a thorough reading of the titles and abstracts of each article was carried out, in order to verify its adequacy with the guiding question of the present investigation. The analysis of the data was structured by identifying the studies with the letter "A" (A1 - article 1, A2 - article 2, and so on) and analyzed by 3 independent reviewers according to the country of publication, technology used and elements of communication. The study was registered in the Coordination of Research and Professional Master's Degree in Family Health at Uninovafapi University Center, with case nº 125/2017.
Results
In total, 464 publications were returned, of which 63 were duplicates and 14 did not provide the abstract, that is, 387 publications were evaluated according to inclusion and exclusion criteria. After reading the titles and abstracts, 24 publications were selected, in which 21 addressed other topics or used different methodologies than the one expected by this research, thus fitting only 3 articles to the selection criteria, as shown in Figure 1.
Source: Direct Search, 2017.
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Figure 1: Flowchart of the study design.
Of the studies selected for analysis, 66.66% are quantitative and 33.33% are retrospective studies. Regarding the countries of publication, 33.33% of the studies were developed in Brazil, 33.33% in Australia and 33.33% in the United States. Regarding the ICTs used, 66.66% used electronic evaluation systems and 33.33% approached a telehealth application, as shown in Table 2.
Table 2 - Characteristics of the studies in relation to the country of origin, year of publication and methodology used, Teresina, Brazil, 2017. Publication Country (Year) Kind of study Information and Communication Technology Used
A1 Brazil Brazil (2017) Quantitative Electronic evaluation system. A2 Australia (2016) Retrospective Telehealth application. A3 United States (2016) Quantitative Electronic Assessment System. Source: Direct Search, 2017.
Table 3 presents the tools of teleodontology evidenced in each study, in which its main relative findings of each publication are described separately according to the PICO strategy (patient, intervention, comparison, outcome).
Table 3 - Tools of teleodontology evidenced, Teresina, Brazil, 2017. Publication Teleodontology tools evidenced and conclusions about their use
A1(11) • Patient: 47 health professionals (32 dentists and 15 non-dentists) enrolled in an oral medicine course on a telehealth platform. • Intervention: Evaluation of participants' diagnostic skills through analysis of 33 clinical images of oral lesions. • Comparison: Analysis of the performance of professionals of different professional categories in the diagnosis of oral lesions, the data of the tests were submitted to descriptive statistics and distributed in the Shapiro-Wilk test and the analysis of the variance through the test (ANOVA) / Tukey or Kruskal -Wallis / Dunn. • Outcome: Both dentists and non-dentists presented a good capacity to discriminate the nature of oral lesions, in which they presented greater specificity in the diagnosis performed by dentists. Such a fact can be attributed to your background and specific training during undergraduate education as well as your professional experience.
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A2(12) • Patient: Participated in the study 126 children in the age group from 2 to 18 years. • Intervention: The children were submitted to intra-oral photographs with a Digital Single Lens Reflex (DSLR) camera before dental treatment by oral health technicians and dentists, in which they were subsequently sent by a telehealth application for the evaluation of specialists, dentists and oral health technicians. • Comparison: Evaluation of the feasibility and reliability of intraoral photographs performed by different components of the oral health team for dental screening in children. • Outcome: The results suggest that the professionals who make up the oral health team have the potential to detect caries from intraoral photographs with the same diagnostic precision and reliability as dentists, implying support for oral health technicians to detect oral diseases in telehealth activities, of great importance in remote areas where it is often devoid of dentists.
A3(13) • Patient: Sample composed of members of the South Carolina Dental Association. • Intervention: The researched population answered a questionnaire electronically and the data were analyzed in a descriptive and bivariate manner. • Comparison: Assessment of knowledge, need, and interest in telehealth activities by members of the South Carolina Dental Association. • Outcome: Despite the lack of knowledge about telehealth activities, this study suggests that there is sufficient interest in the benefits offered by this area, however, it needs more studies to evaluate the feasibility of its use.
Discussion
Accepting the results obtained in this study, (11) the diagnostic abilities of oral cancer were analyzed by primary health care professionals, which comprised a sample of 47 participants (32 dentists and 15 non-dentists) enrolled in a course oral medicine on a telehealth platform, which performed a test based on 33 clinical images of oral lesions and classified each lesion as benign, potentially malignant or malignant. Non-dentists and dentists showed a comparable sensitivity of 68.8% and 63.7%, respectively. The specialists obtained better results, but the difference was not statistically significant (p = 0.16). Dentists and specialists (70.0% and 95.5%, respectively) presented higher specificity than non-dentists. Non-dentists had more unanswered questions for classification and clinical impression than dentists (5.7% and 19.8, respectively). Both (dentists and non-dentists) had low participation in the course. This study suggests that both dentists and non-dentists have a good ability to discriminate the nature of oral lesions, but early squamous cell carcinoma is the most challenging situation and remains a problem of impact in dentistry. The aim of this study was to evaluate the feasibility and reliability of the intraoral photographs performed by different components of the oral health team for dental screening in children, totaling a sample of 126 children aged 2 to 18 years who were submitted to photographs intra-oral with a DSLR camera before dental
134 treatment by oral health technicians and dentists, where they were later sent by a telehealth application for the evaluation of specialists, dentists and oral health technicians. The evaluations of the participants through the photographs, when compared with the specialists obtained a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between expert evaluation and the photographic method (evaluated by dentists and oral health technicians) was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT / dft score for children was determined by expert review and photographic evaluation, ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746). The results suggest that the professionals that make up the oral health team have the potential to detect caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists, implying support for oral health technicians to detect oral diseases in dental activities. telehealth, of great importance in remote areas where it is often devoid of dentists.(12) Other studies that corroborated the use of telehealth tools for the screening of patients. Aziz and Ziccardi(14) analyzed the communication through smartphones between residents and preceptors, where scanned radiographs were sent to the preceptors' smartphone through e-mails, which were answered about the diagnosis and treatment plan of each independent case where the preceptors were in the moment, which improved and accelerated the screening and access of patients to consultations with specialists. Duka et a.(15) verified the reliability of established diagnoses at a distance and indications for third molar extraction, the results indicated almost perfect agreement between the examiners (k = 0.99) and the diagnosis of impacted third molars performed at a distance proved to be as efficient and the one done in person. This study demonstrated the importance of technology and how it can influence effective and quality treatment. Torres-Pereira et al.(16) investigated the feasibility of distant diagnosis in dentistry, through digital photographs and e-mail. Two distant consultants, both dental surgeons, analyzed separately the transmitted images, clinical information and recorded a maximum of two clinical hypotheses for each case. Thus, in 80% of cases, at least one consultant was able to provide the correct diagnosis. With the development of the technology, Petruzzi and Benedittis(17) carried out a study in which they described the use of the WhatsApp application in smartphones in the sharing of clinical information between professionals and patients, evaluating whether this platform could facilitate communication and ensure greater diagnostic speed . The suggested diagnostic hypotheses of communication with the evaluators through the application agreed with the clinical and histopathological report in 82% of the cases, in which the authors concluded that this and similar platforms may be strategies to facilitate the interrelationship among professionals, as well as with the patients, promoting fast service and care for patients with oral pathologies. Martin et al. (13) conducted a study to assess knowledge, need, and interest in telehealth activities for improved care by members of the South Carolina Dental Association. Data were collected electronically and analyzed with SAS and descriptive and bivariate methods. The majority (69.3%) reported little or no knowledge about teleodontology. The distribution of the need for consultations was endodontic (40.2%), buccomaxillofacial surgery (37.9%), orthodontics (30.7%), periodontics (28.4%) and pediatrics (12.5%). Consultations for diagnosis (72.9%), emergencies (56.7%) and continuing education (53.3%) were identified more frequently. The size of the population of patients with the Medicaid telehealth
135 application was the only measure that was statistically significant (<10% Medicaid> 10%) and was more likely to frequently require consultations for orthodontics (25.5%), pediatrics (5 (44.1%), patients with complex health conditions (54.3%), conditions exacerbated by unmet need for dental care (44.6%) and extension of the practice to underserved populations (14.6%). However, there is a need to improve the knowledge about telehealth, there is interest in the area, more detailed studies can be conducted to determine if the demand for teleodontology is in balance with the availability of the consultant. This study also contributed to demonstrate gaps in the several areas that can be used as a diagnostic tool. Bradley et al.(18) carried out a study to analyze the level of interest of primary-care dentists to receive second-opinion support from orthodontics specialists through tele-odontology. as a result a positive response of 46% of the participants, in which they reported the time savings and obtaining a faster opinion to the treatment plan as the best reasons for using the tool. Just under half of dentists who answered answered positively about the benefits of a teleodontology reference scheme. However, a substantial number remained undecided, possibly because they were not sure of their skills in using ICTs. These are public health concerns that are also demonstrated in previous studies.(19-22)
Conclusion
In view of the above, this study concluded that the scientific evidence on diagnosis in teleodontology is referenced with the use of electronic systems and telehealth applications. In addition, it is suggested that these instruments be explored in an amplified way and with the purpose of objectifying the universality of access, reception, integrality, humanization of care and that are widely available for access to the population with high repercussion. These new communication technologies for use in the health area, with a focus on dentistry, are considered aggregating elements in the process of academic and professional formation, aiming to improve access to health services.
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