Introduction

Teledentistry is the use of electronic medical records, information and communication technology (ICT), digital imaging, and the internet to facilitate teleconsultation with specialists, supervision of collaborative practitioners at a distance, and to continue education.1 Before the emergence of ICT, dentists were often communicating via telephone or by sending patient clinical records via post, fax or telegraph. The rapid advance of ICT and availability of the internet have increased the potential of telemedicine applications, speed, and methods by which practitioners and patients can interact.2 Long waiting lists and increased consultation times, and inappropriate referrals have been a source of concern for care providers. Adoption of ICT in dental practice has the potential to reduce inappropriate referrals3 and reduce waiting lists for specialist consultation,4 as well as facilitating timely information to the dentist for better decision making.5

Although teledentistry is a fast-growing field, barriers to its increased use in practice still exist.6 The most pressing challenges in teledentistry practice centre around cost, data security and time management.2 Despite the wide use of telemedicine applications in healthcare, many dentists are still unaware of what teledentistry is, what its potential benefits are, or how they can use it in routine practice.7 As the attitudes of dentists towards telemedicine has not been well examined in the literature, the focus of the present survey was to explore Australian dental practitioners' perceptions of the usefulness of teledentistry for practice, as well as from the patients' perspective, and determine their perceived concerns to the use of ICT in dentistry.

Methods

Survey instrument

An anonymous electronic survey of Australian dental practitioners was carried out in 2014. The survey was adapted from Mandall et al.'s questionnaire which was originally developed to evaluate perceptions of UK general dental practitioners (GDPs) about a teledental system to screen new patient orthodontic referrals.8 The first section of the survey solicited demographic and professional background information, as well as internet access time and preferred methods of communication. The second section of the survey comprised of 24 five-point Likert-type questions and was divided into four domains: practitioners' concerns relating to data security; capability of teledentistry to improve practice; usefulness of teledentistry for patients; and dental practice. The survey was pretested on a group of seven practicing dentists to gain feedback and overall acceptability of the questionnaire and minimal corrections were made based on their response. Ethics approval for this study was obtained from the Human Research Ethics Committee of the University of Western Australia with the protocol number RA/4/1/6,647.

Survey distribution

An email list of dental practitioners was obtained from the contact directory of the International Research Collaborative–Oral Health and Equity. A total of 169 registered dental practitioners working in Australia were randomly selected from that directory (over 1,000 members) as the sample. The random sample shared common demographic and professional characteristics with the Australian dental workforce. The directory is a collective of dental practitioners, mostly general dentists, working in different settings but mainly in urban private practices across the nation. The survey was then distributed by email and was also enclosed with a definition of teledentistry and description of the benefits of telemedicine in addressing many issues in daily practice. Following the initial correspondence, a reminder was sent to all practitioners who did not respond to the first email at fortnightly intervals.

Data analysis

Completed responses were entered into an Excel spreadsheet (Microsoft 2013) and coded for data analysis. The data were analysed using Excel and SPSS (version 17.0). Descriptive statistics were used to summarise demographics and data. Data were expressed as frequencies and valid percentages.

Results

Of the 169 surveys emailed to dental practitioners, 144 responses were returned, indicating a response rate of 85%. Of the 144 respondents, nine provided incomplete responses. Therefore, only 135 completed responses were available for analysis.

Demographic and professional characteristics of respondents

Demographic data found that more than half of the study population was aged above 45 years. Most respondents were practicing general dentists or specialists (75%), males (56%) and had more than 16 years of work experience (64%). The majority of practitioners were working in major cities (77%), and the remainder were either working in regional or remote Australia. While a large proportion of respondents (47%) worked 35–49 hours per week, almost a quarter of respondents worked over 50 hours per week. Despite the majority of respondents working either in private (37%) or public (35%) practices, the proportion of practitioners who worked in both public and private sectors was just less than 25% (Table 1).

Table 1 Description of demographic and professional characteristics of participants
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Internet use and communication method preferences

Less than three-quarters of respondents spent less than four hours on the internet per day for the practice-related purpose (Table 2). With the emergence of ICT and the availability of the internet, tools traditionally used for communication, such as letters, fax or face-to-face, seem to be less preferable. For instance, a minority of respondents used in-person (5%), letters (3%) or fax (1%) as a tool of communication with others. A substantial proportion of respondents rated email (22%) and phone (16%) as a preferred medium for communication. The adoption of social media, forums or video-conferencing was still slow among practitioners (Fig. 1).

Table 2 Showing average daily internet use (in hours) by participants
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Figure 1
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Preferred communication tools among dental practitioners

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Practitioners' concerns relating to security and confidentiality issues

Concerns about the incompatibility of software or hardware tended to be higher than those surrounding privacy, reliability of equipment, and gaining consent, with just over 60% of respondents a little, or very concerned, about technical incompatibility. Although a slim majority of 53% expressed little or great concerns with a potential violation of confidentiality, nearly a third of respondents were either a little or very concerned with gaining patient consent for teledental consultations. On the other hand, uncertainty was observed in the practitioners' views about the reliability of equipment and potential image forgery (Fig. 2).

Figure 2
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Practitioners' concern about data security and patient consent

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Capability of teledentistry system to improve practice

Generally, advantages of the teledentistry system in improving practice were well perceived by most practitioners. More than 80% of respondents agreed or strongly agreed that communication with colleagues, guidance and referral of new patients would be enhanced. However, respondents were unsure if teledentistry would help shorten waiting lists with more than 40% of respondents indicating uncertainty about this statement. Respondents were also unclear in their opinions about whether teledentistry can provide a valid diagnosis compared with a diagnosis within a clinical setting (Fig. 3).

Figure 3
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Practitioners' perception of capability of the teledentistry to improve practice

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Usefulness of a teledentistry system for dental practice

The majority of respondents indicated that teledentistry could be quite useful in improving dental practice by saving time when compared to conventional referral, supplying sufficient diagnostic information, and enhancing clinical training. A slim majority of respondents (52%) felt that teledentistry would not require extra appointments for photography. In contrast, respondents were less convinced that teledentistry would reduce time spent on patients and be too expensive to set up, with over a third of respondents unsure about this statement. Similarly, more than half of respondents (54%) were doubtful as to whether teledentistry would reduce costs for their dental practices (Fig. 4).

Figure 4
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Practitioners' perception of usefulness of the teledentistry for dental practice

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Usefulness of a teledentistry system for patients

Generally, practitioners' beliefs in the potential merits of teledentistry for patients were positive, and up to 70% of respondents agreed or strongly agreed with statements that highlighted the benefits of a teledentistry system. More than 65% of practitioners agreed strongly that a teledentistry system would benefit patients in remote or rural locations. The willingness of respondents to communicate with colleagues and liaise with their patients was also observed, and 80-90% of respondents showed that teledentistry would improve interaction with peers and patients (Fig. 5).

Figure 5
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Practitioners' perception of usefulness of the teledentistry for patients

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Discussion

To our knowledge, this study is the first to evaluate Australian dentists' perceptions about the usefulness of telemedicine in dentistry. Generally, more optimism was expressed by respondents with respect to the advantages of teledentistry for patients, compared with its advantages to dental practice. Most respondents felt that teledentistry would be useful in improving dental practice, patient management, and patient satisfaction. This reflects previous studies that found that dentists are quite open to the use of telemedicine technology in dental practice.8,9,10 A minority of respondents were wary of particular aspects of teledentistry practice. These aspects are largely attributed to practitioners' concerns with cost, time, security and diagnostic accuracy. For some attributes such as the cost of setting up teledentistry, practice expenses and surgery time, the perceptions of usefulness were lower, as a larger proportion of respondents did not express strong views.

Cost, time, security, unclear remuneration guidelines, lack of direct contact and comfort with technology have been identified as barriers to the integration of ICT into clinical practice.9,11,12 Similarly, Australian dentists were solicitous for set-up costs, practice expenses, surgery time, technical incompatibility and security issues. These findings were consistent with concerns expressed by UK GDPs.8 However, this contrasts with those of Canadian orthodontists in a survey which have considered remuneration, security issues and lack of comfort with technology as less important.9,10 Concerns with long surgery times reflect previous reports which show that the time spent to prepare a patient for a teleconsultation is longer than conventional settings.13,14 Increased use of technology in practice has heightened concerns such as security vulnerabilities associated with transmitting unencrypted data, transferring data via an open Wi-Fi hotspot and inappropriate access to databases.2,15 With violation of patient privacy seeming to be easier than ever before, protecting patients' privacy in an electronic environment becomes challenging.16 Therefore, practitioners of teledentistry should put maximum efforts to protect the confidentiality of information.

While increased risk of privacy violation has been cited as an initial barrier for using teledentistry, other issues such as remuneration, licensure, taxation, copyright and medicolegal issues may become a matter of concern.17 Costs of telemedicine equipment and supporting technologies may also represent a burden on providers and governments.18 Nowadays in developed countries it is hard to imagine a dental practice without digital radiography, intraoral cameras, digital cameras, computerised patient registry, and computers with Internet access.19 Therefore, the use of available ICT infrastructure in practices would save the cost of teledental equipment, and reduce practice expenses and consultation costs. Furthermore, despite its ability to make accurate diagnoses,20 there is a growing concern about the diagnostic validity of teledentistry compared with in-person oral examination.3 Uncertainty about diagnostic accuracy may arise from the inability to perform complete investigations when using teledentistry for certain clinical situations, thus, direct patient contact may still be needed to establish an accurate diagnosis.21 Oral diseases also vary in colour, shape, and consistency, and, therefore, a very high quality of oral images is important to allow for online consultation.22

Despite reluctance to the use of digital and electronic technologies such as social media, forums or video-conferencing in communication, other tools like email and phone seem to be the favourable medium of communications. For instance, a survey of 4,000 US doctors indicated that almost two-thirds were communicating with colleagues via email.23 Email can provide clinicians practicing in remote locations with valuable access to the second opinion, since it allows low-cost communication of digital images.24 Therefore, email can offer a richness of communication compared to traditional tools. Furthermore, respondents were more likely to communicate not only with colleagues, but with their patients. This was reflected in their support of the concept that teledentistry would enhance communication, clinical training and guidance among practitioners, and improve interactions with patients. These results were inconsistent with other research showing that dentists are more open to interacting electronically with other dentists than with patients or the public.9,25

Addressing how teledentistry can benefit specific practice aspects would motivate more dental practitioners to actively integrate this technology into daily practice. It would also be helpful to re-evaluate dental practitioners' perceptions as new issues may emerge when teledentistry becomes more widely used. Furthermore, policy-makers must establish well-defined standards and laws that can regulate the use of teledentistry in dental practice.

Conclusion

The majority of respondents expressed positive views towards technology-based solutions and tools that can bring added benefits to dental practices. However, this study has identified certain barriers to the use of teledentistry, and identified where practitioners would need support to use teledentistry technology, especially in aspects related to practice expenses, equipment setup costs, time, technical incompatibility and security.