Dental Caries

Dental Caries is a chronic disease of childhood that has reached epidemic proportions (Garcia-Cortes et al., 2014). The oral health of children is critical for their overall well-being with prompt diagnosis and early management being a key to the success of this approach. Despite significant progress in reducing oral diseases in developed countries over the past three decades, dental caries remains a significant public health problem, particularly amongst disadvantaged people and people living in remote areas (Estai et al., 2017c). Saudi Arabia is a large country with over 700 towns and villages. Despite the growth of dentistry in the Kingdom, there are still very few areas with specialized pediatric dental care. Specialists tend to be concentrated in the major towns and cities (AlShammery, 2016a). This increases the challenge of providing high quality pediatric dental care to every part of the Kingdom. This is a problem, as it is documented that a lack of dental care to the primary teeth will increase the risk of dental problems in the permanent teeth (Li and Wang, 2002). Pediatric dentistry is a complex field with the interaction of many different specialties. Children require not only restorative and endodontic care to the primary teeth but also require consultations from endodontists, prosthodontists and orthodontists on the condition of the tooth and future treatment planning. It is very difficult to locate such multi-disciplinary care even in smaller towns and almost impossible to obtain in remote villages of the Kingdom (AlShammery, 2016a). As a result of this maldistribution in the dental workforce, many rural and remote communities in are left underserved, leading to untreated oral disease (Estai et al., 2017b). Workforce shortages, sparsely populated regions, funding challenges and the decreasing cost of and advances in technology, have resulted in an increased interest in the adoption of telemedicine services (Bradley et al., 2010). The use of role substitution in dentistry is not a new concept. One of the potentially viable solutions to address geographical hurdles and the unavailability of dentists is mobile teledentistry (Estai et al., 2016b). Teledentistry allows local service providers to see advice from specialists without the patient having to leave the local practice (Marino et al., 2016).Teledentistry is a domain of telemedicine that emerges from the combination of information communication technology (ICT) and dentistry. For several decades, telemedicine has played a role in bridging gaps and overcoming barriers related to distance through expanding care access to unreachable populations (Estai et al., 2016a). Teledentistry is defined as the use of electronic information and telecommunications technologies to support long-distance clinical oral health care, patient and professional health related education, public health, and health administration (Marino and Ghanim, 2013). It is one of a number of growing solutions to address limited access to dental care is the utilization of telemedicine technologies in the screening for oral diseases, providing care, evaluation of care and referral (Estai et al., 2016c). There are two telemedicine modalities: real-time consultation and store-and-forward. For most dental applications, the store-and-forward method provides excellent results without excessive costs for equipment or connectivity (Daniel and Kumar, 2014). Mobile teledentistry is a subset of telemedicine that incorporates cellular phone technology and store-and-forward telemedicine into oral care services. Almost all smartphones have a built-in camera and mobile connectivity and are readily accessible at a low cost. (Estai et al., 2016d). Despite dental photography becoming an integral part of daily dental practice, it has rarely been used as means of diagnosis, consultation, or referral in routine practice. However, evidence on the use of smartphone cameras in epidemiological dental research is rare (Estai et al., 2017b).Given the need for specialist consultation in the remote parts of Saudi Arabia, there is a need for a study to examine the reliability of mobile phone teledentistry in the Kingdom. Since the mixed dentition is the period of maximum dental change for a child, this study focused on the use of mobile phone teledentistry in the mixed dentition.1.2 Aim of the StudyThe aim of the study is to test the reliability of mobile phone teledentistry in diagnosis of dental caries of children in the mixed dentition.1.3 Specific Objective of the StudyThe study had the following specific objective, which is to compare the diagnosis of oral caries in the mixed dentition obtained via teledentistry to the diagnosis of these conditions obtained by physical clinical examination.The use of mobile phones and the sharing of photographic data on platforms such as WhatsAppâ„ ¢ or Instagramâ„ ¢ is a relatively new phenomenon. However, the field of teledentistry itself is not new. This literature review tracks the development of telemedicine and teledentistry. It also looks into the validity and reliability of diagnosis made using photographs. Lastly, it seeks to demonstrate the demographic and human resource challenges that highlight the need for teledentistry in Saudi Arabia.2.1 Development of TeledentistryThe development of telemedicine began in the 1960s, when the United States department of defense decided to establish a data base of interconnected networks to provide healthcare to troops stationed in remote locations (Rocca et al., 1999). The US Army conducted the first study of teledentistry at Fort Gordon, Georgia in July 1994. In this study a dental image management system was used in conjunction with an Intra-oral camera to capture color images of a patient's mouth. These images were then transmitted over a 9600 baud modem from the dental clinic in Fort McPherson, Georgia to Fort Gordon, a distance of 120 miles (Rocca et al., 1999).The initial set up for teledentistry, relied on communication via modems and wire based telephonic communication (Eraso et al., 1996). In the 1990s, the internet gained rapid popularity with the public revealing of the World Wide Web, an entity that had hitherto been a secret US army project. This led to the exploration of newer modes of transmitting data. Reviewing the existing systems of the time, Eraso et al (1996) looked at the effect of digitalizing and transmitting tomographic radiographs. Tomograms of the temporomandibular joint were digitized in three different formats using a PC-based system. The image resolution for various projections was determined at different camera-film distances. Three series of images were transmitted by telephone, and transmission times were measured. They found that while no difference in image quality was found between the initial digitized and the transmitted images; transmitted and transmitted-and-printed images were of significantly lower quality than the original radiographs or the digitized images viewed on a computer monitor (Eraso et al., 1996). In the late 1990s, the national electrical manufacturers association had developed a standard guideline for the storage and transmission of images. Digital Imaging and Communications in Medicine (DICOM) is a standard for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and picture archiving and communication systems (PACS) from multiple manufacturers. It has been widely adopted by hospitals, and is making inroads into smaller applications like dentists' and doctors' offices (Bauer and Brown, 2001, Folke, 2001, Chen and Chen, 2002). Chen and Chen (2002) compared DICOM images to existing videoconferencing techniques for the transmission of dental information. They found that DICOM images greatly reduced the cost of transmitting information without significantly compromising quality. The early part of the new millennium was characterized by the rapid spread of e-mail and electronic communications. The launch and spread of several free email providers such as Hotmailâ„ ¢, Gmailâ„ ¢, Yahooâ„ ¢ etc. meant that scanned images could be transmitted between persons without Dental Caries Dental Caries is a chronic disease of childhood that has reached epidemic proportions (Garcia-Cortes et al., 2014). The oral health of children is critical for their overall well-being with prompt diagnosis and early management being a key to the success of this approach. Despite significant progress in reducing oral diseases in developed countries over the past three decades, dental caries remains a significant public health problem, particularly amongst disadvantaged people and people living in remote areas (Estai et al., 2017c). Saudi Arabia is a large country with over 700 towns and villages. Despite the growth of dentistry in the Kingdom, there are still very few areas with specialized pediatric dental care. Specialists tend to be concentrated in the major towns and cities (AlShammery, 2016a). This increases the challenge of providing high quality pediatric dental care to every part of the Kingdom. This is a problem, as it is documented that a lack of dental care to the primary teeth will increase the risk of dental problems in the permanent teeth (Li and Wang, 2002). Pediatric dentistry is a complex field with the interaction of many different specialties. Children require not only restorative and endodontic care to the primary teeth but also require consultations from endodontists, prosthodontists and orthodontists on the condition of the tooth and future treatment planning. It is very difficult to locate such multi-disciplinary care even in smaller towns and almost impossible to obtain in remote villages of the Kingdom (AlShammery, 2016a). As a result of this maldistribution in the dental workforce, many rural and remote communities in are left underserved, leading to untreated oral disease (Estai et al., 2017b). Workforce shortages, sparsely populated regions, funding challenges and the decreasing cost of and advances in technology, have resulted in an increased interest in the adoption of telemedicine services (Bradley et al., 2010). The use of role substitution in dentistry is not a new concept. One of the potentially viable solutions to address geographical hurdles and the unavailability of dentists is mobile teledentistry (Estai et al., 2016b). Teledentistry allows local service providers to see advice from specialists without the patient having to leave the local practice (Marino et al., 2016).Teledentistry is a domain of telemedicine that emerges from the combination of information communication technology (ICT) and dentistry. For several decades, telemedicine has played a role in bridging gaps and overcoming barriers related to distance through expanding care access to unreachable populations (Estai et al., 2016a). Teledentistry is defined as the use of electronic information and telecommunications technologies to support long-distance clinical oral health care, patient and professional health related education, public health, and health administration (Marino and Ghanim, 2013). It is one of a number of growing solutions to address limited access to dental care is the utilization of telemedicine technologies in the screening for oral diseases, providing care, evaluation of care and referral (Estai et al., 2016c). There are two telemedicine modalities: real-time consultation and store-and-forward. For most dental applications, the store-and-forward method provides excellent results without excessive costs for equipment or connectivity (Daniel and Kumar, 2014). Mobile teledentistry is a subset of telemedicine that incorporates cellular phone technology and store-and-forward telemedicine into oral care services. Almost all smartphones have a built-in camera and mobile connectivity and are readily accessible at a low cost. (Estai et al., 2016d). Despite dental photography becoming an integral part of daily dental practice, it has rarely been used as means of diagnosis, consultation, or referral in routine practice. However, evidence on the use of smartphone cameras in epidemiological dental research is rare (Estai et al., 2017b).Given the need for specialist consultation in the remote parts of Saudi Arabia, there is a need for a study to examine the reliability of mobile phone teledentistry in the Kingdom. Since the mixed dentition is the period of maximum dental change for a child, this study focused on the use of mobile phone teledentistry in the mixed dentition.1.2 Aim of the StudyThe aim of the study is to test the reliability of mobile phone teledentistry in diagnosis of dental caries of children in the mixed dentition.1.3 Specific Objective of the StudyThe study had the following specific objective, which is to compare the diagnosis of oral caries in the mixed dentition obtained via teledentistry to the diagnosis of these conditions obtained by physical clinical examination.The use of mobile phones and the sharing of photographic data on platforms such as WhatsAppâ„ ¢ or Instagramâ„ ¢ is a relatively new phenomenon. However, the field of teledentistry itself is not new. This literature review tracks the development of telemedicine and teledentistry. It also looks into the validity and reliability of diagnosis made using photographs. Lastly, it seeks to demonstrate the demographic and human resource challenges that highlight the need for teledentistry in Saudi Arabia.2.1 Development of TeledentistryThe development of telemedicine began in the 1960s, when the United States department of defense decided to establish a data base of interconnected networks to provide healthcare to troops stationed in remote locations (Rocca et al., 1999). The US Army conducted the first study of teledentistry at Fort Gordon, Georgia in July 1994. In this study a dental image management system was used in conjunction with an Intra-oral camera to capture color images of a patient's mouth. These images were then transmitted over a 9600 baud modem from the dental clinic in Fort McPherson, Georgia to Fort Gordon, a distance of 120 miles (Rocca et al., 1999).The initial set up for teledentistry, relied on communication via modems and wire based telephonic communication (Eraso et al., 1996). In the 1990s, the internet gained rapid popularity with the public revealing of the World Wide Web, an entity that had hitherto been a secret US army project. This led to the exploration of newer modes of transmitting data. Reviewing the existing systems of the time, Eraso et al (1996) looked at the effect of digitalizing and transmitting tomographic radiographs. Tomograms of the temporomandibular joint were digitized in three different formats using a PC-based system. The image resolution for various projections was determined at different camera-film distances. Three series of images were transmitted by telephone, and transmission times were measured. They found that while no difference in image quality was found between the initial digitized and the transmitted images; transmitted and transmitted-and-printed images were of significantly lower quality than the original radiographs or the digitized images viewed on a computer monitor (Eraso et al., 1996). In the late 1990s, the national electrical manufacturers association had developed a standard guideline for the storage and transmission of images. Digital Imaging and Communications in Medicine (DICOM) is a standard for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and picture archiving and communication systems (PACS) from multiple manufacturers. It has been widely adopted by hospitals, and is making inroads into smaller applications like dentists' and doctors' offices (Bauer and Brown, 2001, Folke, 2001, Chen and Chen, 2002). Chen and Chen (2002) compared DICOM images to existing videoconferencing techniques for the transmission of dental information. They found that DICOM images greatly reduced the cost of transmitting information without significantly compromising quality. The early part of the new millennium was characterized by the rapid spread of e-mail and electronic communications. The launch and spread of several free email providers such as Hotmailâ„ ¢, Gmailâ„ ¢, Yahooâ„ ¢ etc. meant that scanned images could be transmitted between persons without