Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

www.stomaeduj.com

Review Article

23-34

EVIDENCEBASED APPLICATION OF TELEDENTISTRY:

A SYSTEMATIC REVIEW

Tin Zar Tun

1,2a

, Raksanan Karawekpanyawong

, Takashi Hoshino

, Bandana Pathak

, Hikaru Okubo

Kaung Myat Thwin

, Sachiko Takehara

, Hiroshi Ogawa

1h*



Department of Oral Health Science, Graduate School of Medical and Dental Sciences, Faculty of Dentistry, Niigata University, Niigata, Japan



Department of Pediatric Dentistry, University of Dental Medicine, Yangon, Myanmar



Department of Community Dentistry, Faculty of Dentistry, Mahidol University, Thailand

MDSc, Lecturer; e-mail: tinajpn@gmail.com; ORCIDiD: https://orcid.org/---

DDS, PhD, Lecturer; e-mail: raksanan.kar@mahidol.edu; ORCIDiD: https://orcid.org/---

DDS, PhD, Assistant Professor; e-mail: takashi-hoshino@dent.niigata-u.ac.jp; ORCIDiD: https://orcid.org/---

DDS, Graduate Student; e-mail: bandanapathak@gmail.com; ORCIDiD: https://orcid.org/---

DDS, Graduate Student; e-mail: hikaru@dent.niigata-u.ac.jp; ORCIDiD: https://orcid.org/---

DDS, PhD, Assistant Professor; e-mail: kaung@dent.niigata-u.ac.jp; ORCIDiD: https://orcid.org/---

DDS, PhD, Associate Professor; e-mail: takeh@dent.niigata-u.ac.jp; ORCIDiD: https://orcid.org/---

DDS, PhD, Professor, and Head; e-mail: ogahpre@dent.niigata-u.ac.jp; ORCIDiD: https://orcid.org/---

Background Teledentistry has emerged as a potential alternative to in-person dentistry, oering new

possibilities for oral healthcare delivery and prompting need for a comprehensive evaluation of its ecacy

and global applicability.

Objective To determine most common elds of teledentistry application, evaluate its eectiveness compared

to in-person dentistry, and analyze its utilization in various countries based on the economic context.

Data source This systematic review conducted a literature search from ve electronic databases: PubMed,

Embase, Web of Science, Clinical Trials.gov, and the International Clinical Trials Registry Platform.

Study selection Evidence-based studies published in English (2011-2021), using teledentistry.

Data extraction Primary outcome: teledentistry usability. Secondary focus: utilization across economic strata.

Methodological quality was assessed using the Down and Black checklist.

Data synthesis Of 34 reviewed studies, 18 favored a combined approach, 6 found comparable ecacies,

9 favored teledentistry, and 1 preferred in-person dentistry for anxiety management. Eectiveness was

evident across economic settings (22 high-income, 6 upper-middle-income, 6 lower-middle-income nations).

Teledentistry showed ecacy in oral health promotion and interprofessional consultation. We found that

orthodontics is the most common specialty in teledentistry. Generally, teledentistry showed positive

outcomes in patient education and behavior modication across various dental specialties. The adoption

of teledentistry adoption might depend on economic status, highlighting the need for further research and

implementation strategies in low-income countries to address global oral health disparities. This review

demonstrates teledentistry’s eectiveness as a versatile tool across diverse economic settings, emphasizing

the need for focused research in low-income regions to bridge the global oral healthcare divide.

Dentistry; Teledentistry; Oral Health; Mobile Applications; Evidence-Based.

OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.

Peer-Reviewed Article

Citation: Wun TZ, Karawekpanyawong R, Hoshino T, Pathak B, Okubo H, Thwin KM, Takehara S, Ogawa H. Evidence-based application of teledentistry: a

systematic review. Stoma Edu J. 2024;11(1-2):23-34.

Received: July 22, 2024; Revised: July 27, 2024; Accepted: August 15, 2024; Published: September 03, 2024.

*Corresponding author: Prof. Hiroshi Ogawa, PhD and Head, Division of Preventive Dentistry, Graduate School of Medical and Dental Sciences, Niigata

University. 2-5274, Gakkocho-Dori, Chuo-Ku, Niigata, Japan 951-8514 Tel/Fax: +81-25-227-2858 E-mail:

ogahpre@dent.niigata-u.ac.jp

ABSTRACT

KEYWORDS

1. INTRODUCTION

The COVID-19 pandemic precipitated an unpre-

cedented crisis in healthcare systems globally, with

oral health services particularly aected due to the

inherent risks associated with conventional dental

practices. The generation of potentially virus-laden

aerosols and droplets during face-to-face dental

interventions posed signicant challenges to the

continuity of care, even with stringent infection

control protocols [1,2].

To address these challenges, the implementation

of health promotion strategies became even

more crucial. One of these is Mobile Oral Health

(mOralHealth), which primarily focuses on enhancing

oral health through knowledge dissemination, skill

development, and community-based healthcare

access [3]. These interventions helped sustain oral

health services during the pandemic by providing

alternative ways to deliver care, thus reducing the

risk of virus transmission while ensuring patients

continued to receive necessary dental support.

https://doi.org/10.25241/stomaeduj.2024.11(1-2).art.1

DENTAL ERGONOMICS

Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

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Review Article

Tun TZ et al.

23-34

One oral health intervention is teledentistry, which

addresses remote diagnosis and treatment planning

via communication technologies [4].

The World Health Organization (WHO) and the

American Dental Association (ADA) dene tele-

dentistry as providing health services using

electronic information, imaging, and communication

technologies to deliver and support oral healthcare

services such as dentist-patient communication, and

inter-professional communication among general

dental practitioners, dental specialists, and medical

professionals from other disciplines [5], particularly in

situations where geographical proximity is a critical

factor [6]. ADA further delineates teledentistry into

four primary modalities: synchronous (live video),

asynchronous (store and forward), remote patient

monitoring (RPM), and health education (mHealth)

[7]. The wide array of teledentistry interventions

includes diagnosis (tele-diagnosis), consultation

(tele-consultation), treatment (tele-treatment), and

dental information dissemination and education

(tele-education) through interactive audiovisual

aids and data communication systems [8].

Although there is empirical evidence suggesting

that teledentistry can eectively complement in-

person management [9], with diverse applications

ranging from patient education on oral health and

hygiene improvement, particularly in orthodontic

patients [10-12], to enhancing specic dental hygiene

practices through various digital platforms [13-17],

there is a signicant gap in the literature regarding

the applicability of teledentistry concerning vari-

ous countries' economic status. Low-income coun-

tries may nd it challenging to implement such

teledentistry interventions, considering factors

such as dental clinic availability and geographical

accessibility.

Research has shown that conventional dental

treatment integrated with digital support has

demonstrated the potential for improving diagnostic

accuracy, treatment ecacy, and prognostic

outcomes [18-21]. However, comprehensive research

evaluating the eectiveness of teledentistry

encompassing diagnosis, consultation, and treat-

ment compared to in-person dentistry across various

dental specialties remains limited. Therefore, the

eectiveness of teledentistry compared to in-person

dentistry in the elds of dentistry was evaluated in

this systematic review.

2. METHODS

This study employs a systematic review methodology

to determine the most common elds of teledentistry

application, evaluate its eectiveness compared

to in-person dentistry, and analyze its utilization in

various countries across diverse economic contexts.

The research protocol adheres to the Preferred

Reporting Items for Systematic Reviews and Meta-

Analyses (PRISMA) 2020 guidelines and is registered

with the International Prospective Register of

Systematic Reviews (Registration Number CRD

42022259600) [22].

2.1. Search strategy and focused questions

A comprehensive literature search was conducted

across ve electronic databases: PubMed,

Embase, Web of Science, ClinicalTrials.gov, and

the International Clinical Trials Registry Platform.

Supplementary hand searches were performed to

ensure comprehensive coverage. Detailed infor-

mation is provided in supplementary Table 1.

The following three questions were formulated using

the PICO approach to assess whether teledentistry is

No. Authors/ Year

of Publication

(Country)

Study

Population

Target age

groups

(Number of

Subjects)

Tele-dentistry

Intervention(s)

Form of Tele-

communication/

Devices

Comparison

Group

Main

Outcomes

Summary of

results

Orthodontic Dentistry

1 Jejurikar et al.,

2014 (India)

patients

(full ﬁxed

appliances in

both arches)

Young adults: 13-19

years (n=50)

Weekly text message

reminders after OHI, once a

week for 4 months

Remote patient

monitoring (RPM)

Only OHI Plaque index

(PI), white spot

lesions (WSL)

2 Eppright et al.,

2014 (USA)

patients

(active

treatment

with full ﬁxed

appliances in

both arches)

Young adults: 11-19

years (n=42)

One parent or guardian of

each patient received a text

message and the patient

received oral hygiene

instruction.

Mobile health

(mHealth)

Only Oral

hygiene

instruction

Bleeding index

(BI), Modiﬁed

Gingival Index

(MGI), and

Plaque Index

(PI)

∂

3 Bowen et al.,

2015 (USA)

patients (ﬁxed

maxillary

edgewise

appliances)

Young adults:

10-18 years (n=50)

Audiovisual presentation on

oral hygiene care followed

by 2-3 text messages per

week for 4 weeks, then 1

text message per week for

8 weeks.

Asynchronous

(store and

forward)

Only

audiovisual

presentation

about oral

hygiene care

Planimetry-

based

evaluation of

plaque values

evaluation

(Digimizer

software)

4 Al-Silwadi et al.

2015 (United

Kingdom)

patients

(scheduled to

receive ﬁxed

orthodontic

appliance)

Others: ≥13 years

(n=60)

Following the distribution

of oral health education and

leaﬂets on oral health and

ﬁxed appliance care, an email

was sent inviting participants

to view a video providing the

same information.

Other Only oral

health

education,

leaﬂets on oral

health and

care of ﬁxed

appliances

Knowledge

of dental and

appliance care

Table 1. Characteristics of the Included Studies.

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5 Abdaljawwad,

2016 (Iraq)

patients (ﬁxed

orthodontic

appliances)

Young adults:

17-23 years

(n=34)

After OHI, text messages

twice a week for 4 weeks and

once a week for 8 weeks.

Asynchronous

(store and

forward)

Only OHI Bleeding Index

(BI), Modiﬁed

Gingival Index

(MGI), Plaque

Index (PI)

6 Cozzani et al.,

2016 (Italy)

patients

(begin ﬁxed

orthodontic

treatment)

Others: mean age:

13.5 ± 1.7 years

(n=84)

1. after the OHI, a reinforced

text message

2. phone call 5-7 hours after

initial bonding

Mobile health

(mHealth)

Only OHI Oral Hygiene

Index, by

Silness and

Loe's Modiﬁed

Index, Plaque

Index (PI)

7 Zotti et al.,

2016 (Italy)

patients

(full ﬁxed

appliances in

both arches)

Others: mean age:

control group 13.6

years, study group

14.1 years (n=80)

OHI by taking video tutorials

in WhatsApp chat rooms and

sharing selﬁes as part of the

"Brush Game.

Asynchronous

(store and

forward)

Only OHI Plaque index

(PI), gingival

index (GI),

white spot

(WS), caries

presence

8 Li et al., 2016

(China)

patients

(begin ﬁxed

appliance and

single-phase

orthodontic

treatment)

Young adults: 12-21

years (n=244)

Signed up for a WeChat

account and received twice-

weekly behavioral reminders

and 2-3 educational messages

per week throughout the

treatment period.

Mobile health

(mHealth)

Only

orthodontic

strategy and

pretreatment

education as

in the WeChat

group

Length of

treatment

Failure to keep

appointments,

tardiness

Bracket bond

failure

Orthodontic

PI, modiﬁed

gingivitis index

∂

9 Iqbal et al.,

2017 (Pakistan)

patients

(full-ﬁxed

orthodontic

appliances)

Young adults:

15-25 years

(n=100)

Weekly text message

reminders after OHI for 60

days

Asynchronous

(store and

forward)

Only OHI Bleeding Index

(BI), Modiﬁed

Gingival Index

(MGI), Plaque

Index (PI)

10 Alkadhi et al.,

2017 (Saudi

Arabia)

patients (ﬁxed

orthodontic

appliances)

Others: ≥12 years

(n=44)

Mobile application for video

oral hygiene instruction and

proactive reminders three

times a day for one month.

Mobile health

(mHealth)

Only OHI

during visits

Plaque and

Gingival indices

(PI and GI)

∂

11 Kumar et al.,

2018 (India)

patients (ﬁxed

orthodontic

appliances)

Young adults: 13-19

years (n=60)

Weekly text message

reminders after OHI for 3

months

Asynchronous

(store and

forward)

Only OHI Plaque index

(PI) and WSL

status

12 Deleuse et al.,

2020 (Belgium)

patients

(full-ﬁxed

orthodontic

appliances)

Young Adults: 12-

18 years (n=38)

Interactive oscillating/

rotating electric toothbrush

connected to a brushing

assistance app

Mobile health

(mHealth)

Only

oscillating/

rotating

electric

toothbrush

Plaque index

(PI), gingival

index (GI),

white spot

lesion (WSL)

13 Scheerman

et al., 2020

(Netherlands)

patients (ﬁxed

orthodontic

appliances)

Others: mean

age: study group

13.2±1.01

years, control

group13.5±0.97

years (n=121)

Use the "White Teeth" mobile

application to reinforce

plaque control daily for 12

weeks.

Mobile health

(mHealth)

OHI and

oral health

education

when dental

visits

Plaque index

(PI) and

Bleeding on

marginal

probing index

(BOMP)

14 Al-Moghrabi et

al., 2020 (UK)

participants

(scheduled

for removable

retention with

thermoplastic

retainer (TPR))

Young adults:

12–21 years

(n=84)

Use "My Retainers", a mobile

application that reminds users

to wear orthodontic retainers

Mobile health

(mHealth)

Reminder of

retainer wear

chart

Stability, plaque

level, bleeding

during probing

and depth of

probing, level

of patient

experience and

knowledge

regarding

retainers

15 Farhadifard et

al., 2020 (Iran)

patients

(started

their ﬁxed

orthodontic

treatment)

Others: mean age:

study group 18.7 ±

3.87 years, control

group: 19.27 ±

3.65 years (n=120)

In addition to conventional

oral hygiene instruction, the

team educated the patients to

use a smartphone app (Brush

DJ) that includes timers and

daily reminders to assist in

improving oral hygiene.

Mobile health

(mHealth)

Conventional

oral hygiene

instruction

Plaque Index

(PI) and

Gingival Index

(GI)

∂

16 Sangalli et al.,

2021 (Hong

Kong)

patients

(scheduled

to start an

orthodontic

treatment)

Others: mean

age: study group

24.9±10.9 years,

control group:

6.3±3.2 years

(n=30)

A scan box and cheek retractor

(Dental Monitoring@) were

provided and the patient

was instructed to perform a

monthly intraoral scan.

Remote patient

monitoring (RPM)

Only in-person

toothbrushing

instruction

Plaque Index

(PI), Gingival

Index (GI), and

White Spot

Lesions (WSL)

Preventive Dentistry

17 Jadhav et al.,

2016 (India)

social work

colleges (two

diﬀerent)

Young adults: 18-20

years (n=400)

OHI and oral health education

followed by oral health

education text messages sent

twice a week for 3 months

Mobile health

(mHealth)

Only OHI and

oral health

education

Oral Hygiene

Index and

Gingival Index

(GI)

Review Article

Evidence-based application of teledentistry: a systematic review

23-35

Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

www.stomaeduj.com

18 Williams et

al.,2018 (USA)

participants

(mild to

moderate

periodontitis)

Adults: 21-80 years

(n=60)

View oral hygiene instruction,

brushing and ﬂossing

presentations on computer

Asynchronous

(store and

forward)

Only OHI with

visual aids

Plaque score

(PS) and

bleeding index

(BL)

19 Marchetti et al.,

2018 (Brazil)

students

(technical high

school)

Young adults: 14-19

years (n=263)

1. Verbal oral health

education and reinforced

messages via mobile app for

30 days.

2. oral health education video

and reinforced messages via

mobile app for 30 days.

3. oral health education

video only

Mobile health

(mHealth)

Only verbal

oral health

education

Knowledge

Score (KS),

simpliﬁed

oral hygiene

index (OHI-S),

Gingival

Bleeding Index

(GBI)

20 Araújo et al.,

2019 (Portugal)

patients (>

20 teeth,

and bleeding

on marginal

probing index

over 0.5)

Others: mean age:

control group 13.6

years, study group

14.1 years

OHI using intraoral camera

during the visit and/or text

messages between visits

Asynchronous

(store and

forward)

Only OHI Bleeding on

marginal

probing

(BOPM), dental

hygiene,

behavior

change

21 Scheerman et

al., 2020 (Iran)

students

(public high

school)

Others: high school

students, 12–17

years, with and

without their

mothers

(n=791)

1. use of the Dental Health

telegram channel for patients

to receive oral hygiene

education via text message

or video

2. use of the Telegram

channel for mothers to receive

oral health education and

instructions for teaching and

monitoring their children's

oral health.

Combination Without

intervention

Psychosocial

variables,

toothbrushing

behavior,

Visual Plaque

Index (VPI),

Community

Periodontal

Index (CPI)

√

22 Vpk et al., 2020

(India)

patients

(cerebral

palsy)

Children: 4-12 years

(n=53)

Video based oral health

education following OHI

Mobile health

(mHealth)

Only OHI Oral hygiene

status,

including the

simpliﬁed oral

hygiene index

(OHI-S), plaque

index (PI), and

gingival index

(GI)

23 Shida et al.,

2020 (Japan)

participants

(Kyoto

University)

Others: ≥18 years,

mean age: control

group 25.0 years,

study group 26.0

years (n=112)

After the video based OHI,

a real-time visualization

brushing instruction device

(GUMPLAY) linked to a mobile

application was used for 4

weeks.

Mobile health

(mHealth)

After the OHI

by video, brush

with the same

device without

connecting

it to the

application.

Plaque control

record (PCR)

score

24 Marchetti et al.,

2020 (Brazil)

students (high

school)

Young adults: 14-19

years (n=291)

Video-based dental

ﬂossing and counseling to

communicate oral hygiene

knowledge twice a day for 30

days (VD + smartphone app,

VD without app)

Mobile health

(mHealth)

Dental ﬂoss

and oral

counseling

(OR+ app, OR

without app)

Simpliﬁed

oral hygiene

index (OHI-S)

and gingival

bleeding index

(GBI)

∂

25 Lee et al., 2021

(Korea)

adults

(enrolled

at a senior

college and

senior welfare

center)

Others: ≥65 years

(n=73)

1. Receive lecture-type oral

health education using

PowerPoint slides (non-app

use group)

2. Receive oral health

education using a smartphone

application developed in

this study.

Mobile health

(mHealth)

Without

intervention

Oral health

knowledge

score, O'Leary

index, and

tongue coating

Pediatric Dentistry

26 Plonka et al.,

2013 (Australia)

children

(areas of low

socioeconomic

status)

Others: Infants

within two months

of birth and

caregivers (n=246)

Home visits and phone calls Other Without

intervention

Prevalence of

Early Childhood

Caries (ECC)

∂

27 Hashemian et

al., 2015 (USA)

Mothers

(bringing a

child aged

5 years or

younger for

dental care)

Others: 18-56 years Along with the usual care

printed materials, they

received text messages

regarding oral health

information.

Mobile health

(mHealth)

Only the usual

print materials

Oral health

knowledge

and oral health

behaviors

(including

improving

oral health

behaviors for

their children)

Review Article

Tun TZ et al.

23-34

Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

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28 Iskander, M., et

al., 2016 (USA)

adult

(accompanied

a child to

the dental

appointment)

Adults

36-45 years (n=89)

Oral health education with

"Dental Trauma mobile

healthcare" application

(permanent tooth avulsion

scenario)

Mobile health

(mHealth)

Oral health

education with

"Save Your

Tooth" poster

(assuming

primary tooth

injury)

Knowledge

of permanent

tooth avulsion

∂

29 Zotti et al.,

2019 (Italy)

patients (3

private dental

practices)

Others: 4-7 years

with one of their

parents (n=100)

Use the OHI motivational

mobile apps "Time2Brush"

and "Brusheez-The Little

Monsters Toothbrush Timer"

for children over and under

ﬁve, respectively.

Mobile health

(mHealth)

Only OHI Plaque Index

(PI), presence

of caries,

localization of

carious lesions

30 Alkilzy et

al., 2019

(Germany)

children

(an almost

complete

deciduous

dentition)

Children: mean

age: 5.1 ± 0.6 years

(n=49)

OHI adds toothbrush mobile

application

Mobile health

(mHealth)

Only OHI Plaque and

papillary

bleeding indices

(QHI, PBI)

Oral and Maxillofacial Surgery

31 Salazar-

Fernandez

et al., 2012

(Spain)

patients

(TMDs)

Children:

1-5 years (n=1052)

Digital TMJ and panoramic

radiographic consultation via

intranet e-mail

Asynchronous

(store and

forward)

Conventional

consultation

system at the

hospitals

Clinical

eﬀectiveness,

consultation

costs, and

patient

satisfaction

32 Wang et al.,

2019 (Taiwan)

patients

(admitted

at a general

hospital

for curative

oral cancer

surgery)

Adults: 30–82 years

(n=60)

A 12-week intervention

program (warm compresses,

masticatory muscle massage,

and jaw exercises) three

times a day, with additional

telephone support after

discharge.

Other Only 12-week

intervention

program

Maximum

Interincisal

Opening (MIO)

33 Takeuchi-Sato

et al., 2019

(Japan)

patients

(TMDs)

Others: mean age:

30.7 ± 8.7 years,

(n=30)

Cognitive Behavioral Therapy

(CBT), email recording and

reminder system, sticky note

reminders

Mobile health

(mHealth)

Brief oral

instructions to

avoid non-

functional

tooth contact

(n-FTC) during

the day

Pain-free

opening aid

∂

34 Omezli et al.,

2020 (Turkey)

patients

(scheduled

to undergo

impacted

lower third

molar

removal)

Others: mean age:

study group 22.93

± 5.83 years,

control group

23.12 ± 4.99 years

(n=113)

Third molar surgery video Other Third molar

surgery verbal

information

Anxiety

more eective than in-person dentistry in contem-

porary dental elds:

1. In which dentistry elds is teledentistry most

utilized?

2. How does the eectiveness of teledentistry

compare to in-person dentistry in terms of patient

education, behavior modication, professional

communication, and cost-eectiveness?

3. In which countries is teledentistry more frequently

utilized based on economic context?

2.2. Eligibility Criteria

The study included evidence-based research

published in English between January 2011 and

December 2021, focusing on teledentistry inter-

ventions. Eligible studies involved participants of all

ages and sexes who received teledentistry services,

with conventional dental treatment or oral health

instruction as the control or comparison group.

Primary outcomes assessed teledentistry's usability

through clinical indices, behavioral modications,

Knowledge_Attitude_Practice (KAP) metrics, or cost-

eectiveness analyses, while a secondary outcome

explored teledentistry utilization concerning coun-

tries' economic status. Studies were excluded if they

lacked comparison with conventional methods, were

not original research, or were not written in English.

2.3. Study selection, and data extraction

Two independent reviewers (TH and BP) conducted

the literature review and screened titles and

abstracts to identify studies that met the inclusion

and exclusion criteria. They compiled lists of selected

studies for each research question, which were then

compared. By discussing each source, they reached

a denitive consensus on which studies to include

for each question. Any discrepancies during the

screening and selection processes were resolved

through discussions between the two reviewers. If

disagreements persisted, additional reviewers (RK

and TZ) were consulted to reach a consensus. Once

consensus was reached, the full texts of the selected

literature were collected and independently asse-

ssed by the same reviewers. Only studies with

sucient data were included in the analysis, with

discrepancies resolved through discussion. The

reviewers extracted data using a standardized form,

collecting general information such as authors, title,

Review Article

Evidence-based application of teledentistry: a systematic review

∂ Teledentistry is more favorable than the conventional method, Teledentistry is not dierent from the conventional method, Teledentistry along with

conventional methods is more eective than conventional ones alone, ¢ Teledentistry is less favorable than the conventional method, √ others (Teleden

tistry was eective to deliver oral health education among high-school students, especially with the involvement of their mothers),

OHI – Oral Health Instruction

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Review Article

23-34

year of publication, journal name, study aims, design,

level of evidence, relation to COVID-19, number of

participants, countries of research, study setting,

dental specialty, type, and mode of teledentistry

intervention, comparison with in-person dentistry,

and outcomes. Outcome information was extracted

from the included studies.

2.4. Quality Assessment

Two reviewers independently assessed the quality

and risk of bias in the data extraction process,

following the guidelines from a modied version of

the Downs and Black checklist [23]. The quality of

each including randomized controlled trials (RCTs),

and non-randomized controlled trials (NRCTs) was

evaluated. This instrument evaluates the risk of

bias across 27 items in ve sub-scales (Table 3). This

instrument is based on the following components

that dene study quality and evaluate the risk of

bias: reporting, external validity, internal validity

(bias and confounding (selection bias)), and power.

The bias was rated on a 4-point scale (No risk 0,

partial risk 1, clear risk 2, UTD unable to determine)

for each domain, depending on the reviewers. The

studies were categorized into four quality levels

based on their scores [24] (Table 4). The risk of bias

was summarized by considering the assessments for

each domain and synthesizing them into an overall

judgment of the study: (excellent 26-28; Good 20-25;

Fair 15 -19 or poor less than or equal to 14). Further

disagreements were resolved through discussion

with input from other reviewers (RK and TZ).

2.5. Data synthesis and management

Data synthesis and management were facilitated

through Microsoft Excel. The citation management

tool Endnote X9 (Clarivate Analytics, New York,

United States) was used for reference management.

2.6. Reporting

The PRISMA owchart and checklist were utilized to

ensure transparent and comprehensive reporting of

the literature search and review process.

3. RESULTS

3.1. Characteristics of the included articles

This systematic review analyzed 34 studies, com-

prising 31 randomized controlled trials and three

nonrandomized controlled trials [5,15,25]. The

literature search across multiple databases yielded

1,689 initial results, with 34 articles meeting the

inclusion criteria after rigorous screening (Figure

1). The excluded studies are detailed in the

supplementary materials (Table 2).

The included studies demonstrated the signicant

utility of teledentistry at individual level, primarily

in oral health education, behavioral modication,

and reinforcement. Most studies were conducted

in educational settings (high schools and dental

colleges) and healthcare facilities. One study speci-

cally examined professional communication [5]

while several incorporated follow-up reminder

systems. Notably, no studies provided evidence

of tele-treatment implementation. The primary

outcome measures utilized were clinical indices,

often in combination with knowledge assessments,

Tun TZ et al.

Figure 1. PRISMA flowchart: This diagram illustrates the methodological procedure used to incorporate publications in the systematic review of

teledentistry (2011–2021)..

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Outcome measures Orthodontic

Dentistry

Preventive

Dentistry

Pediatric

Dentistry

Oral and

Maxillofacial

Surgery

Total number of

studies

Clinical Indices 13 5 3 3 24

KAP 1 0 1 0 2

Clinical Indices & KAP 1 2 0 0 3

Clinical Indices and behavior modiﬁcation 1 2 0 0 3

Behavior modiﬁcations and KAP 0 0 1 0 1

Cost and satisfaction 0 0 0 1 1

behavioral modications, Knowledge-Attitude-

Practice (KAP) evaluations, and cost-eectiveness

analyses.

3.2. Quality assessment results

An evaluation of 34 teledentistry studies using the

Downs and Black checklist revealed varied quality

levels (Table 4). While nearly half (47.1%) of the

studies were rated as good quality, about one-fth

(20.5%) were considered poor, and none achieved

excellent quality.

Most of the articles demonstrated high standards in

reporting quality. However, specic methodological

concerns were identied in two studies: one lacked

external validity [10], potentially limiting the

generalizability of its ndings, while another one

exhibited a high risk of internal validity [26], which

may aect the reliability of its results.

Notably, over two-thirds of the studies had sucient

statistical power to detect treatment eects,

indicating appropriate sample sizes and analyses to

support their conclusions. This assessment provides a

crucial context for interpreting teledentistry research,

highlighting strengths and weaknesses. It oers

valuable insights into the overall quality of evidence.

Article No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Reporting 8 7 6 9 6 9 8 5 9 6 6 10 7 5 9 6 6 9 10 9 7 10 8 9 10 9 10 10 8 10 10 8 9 10

external validity 1 3 1 1 1 1 2 1 2 1 1 2 1 1 2 1 1 1 1 1 1 2 2 0 2 2 1 2 2 1 2 2 3 1

internal validity - bias 3 1 4 5 5 5 3 4 7 6 4 5 6 5 5 4 5 6 6 4 7 7 4 4 6 6 7 6 6 6 5 5 5 3

internal validity -

confounding (selection bias)

1 3 1 3 3 5 2 0 4 2 2 4 0 1 4 1 2 5 4 3 3 5 5 4 6 6 3 5 4 4 5 4 4 2

Power 0 1 0 0 1 1 1 0 1 1 0 1 1 0 1 0 0 1 0 1 1 1 1 1 1 0 1 1 0 1 1 1 1 1

Overall Score 13 15 12 18 16 20 16 10 23 16 13 22 15 12 21 12 14 22 21 18 19 25 20 18 25 23 22 24 20 22 23 20 22 17

Quality * ** * ** ** ‡ ** * ‡ ** * ‡ ** * ‡ * * ‡ ‡ ** ** ‡ ** ** ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ **

3.3. Teledentistry usage according to elds of dentistry

According to the current review, teledentistry

interventions can be broadly categorized into

three groups: customized applications for oral

health education, in-oce education with remote

reinforcement measures, and supervision tools

connecting specialists with general dentists to

minimize referrals. Table 2 provides a comprehensive

distribution of study outcomes across various dental

specialties.

The studies included covered various dental

specialties, with orthodontics (15 studies) being the

most represented [10-14,17,20,25,27-34], followed

by preventive dentistry (8 studies) [15,18,21,35-

40], pediatric dentistry (5 studies) [26,41-44], and

oral and maxillofacial surgery (5 studies) [5,19,45,

46]. Each specialty employed diverse objectives,

methodologies, and outcome measures to assess

teledentistry's ecacy compared to in-person

dentistry. Studies predominantly emphasized three

key areas: clinical indices, oral health knowledge and

behaviors, and overall clinical eectiveness.

3.3.1. Orthodontic Dentistry

Most studies indicate that a combined approach

of teledentistry and in-person dental practices can

enhance oral health outcomes for orthodontic

treatment. Digital health technologies, including

mobile applications, SMS notications, telephone

communications, and specialized software, have

proven eective for patient appointment reminders

and engagement. A signicant number of orthodontic

studies (nine in total) advocate for this integrated

approach to improve the oral health of orthodontic

patients. While four studies demonstrated that

teledentistry outperformed in-person dentistry

in enhancing oral hygiene, two studies found no

signicant dierence between the two approaches.

Regarding outcome measures, clinical indices such

as plaque index, gingival index, and bleeding on

probing are predominantly used according to the

study. Many studies utilized clinical indices and

assessments of patient knowledge or evaluations of

behavioral modications. It is worth noting that one

study employed a Knowledge, Attitude, and Practice

(KAP) assessment as an outcome measure. The

methodologies and ndings underscore the evolving

nature of teledentistry applications in orthodontic

care.

Review Article

Evidence-based application of teledentistry: a systematic review

Table 2. Different outcomes measure of included studies.

KAP refers to the knowledge, attitude, and practice of the participants. Detailed outcome measures are reported in Table 1.

‡ Good quality, ** Fair quality, * Poor quality, [excellent (26–28); good (20–25); fair (15–19); and poor (≤14)]

Table 4. Quality assessment result of included studies.

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Review Article

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3.3.2. Preventive Dentistry

This systematic review reveals that preventive

dentistry is the second most prevalent eld for

teledentistry applications. Integrating teledentistry

with in-person dental practices shows considerable

promise. While some research suggests that both

are comparably eective, other studies argue that

teledentistry demonstrates superior outcomes.

Notably, teledentistry has shown ecacy in disse-

minating oral health education within high school

settings.

Similar to the studies in orthodontics, clinical indices

are predominantly utilized as primary outcome

measures. However, a more comprehensive

approach is often adopted, combining these clinical

indices with assessments of patient knowledge

or evaluations of behavioral modications. This

provides a more holistic understanding of tele-

dentistry's impact on preventive dental care,

encompassing both clinical outcomes and patient-

centered factors.

3.3.3. Pediatric Dentistry

Three studies advocate for an integrated approach

that combines teledentistry with conventional

methods. However, two additional studies propose

that teledentistry alone may oer superior outcomes

in pediatric dental care.

Regarding the outcome measures, most pediatric

dentistry studies rely on clinical indices as their

primary evaluation tool. This approach aligns with

the broader trend observed across dental specialties.

Notably, two studies employ alternative assessment

methods: one focuses on behavioral modication

outcomes, while another utilizes the Knowledge,

Attitude, and Practice (KAP) assessment.

3.3.4. Oral and Maxillofacial Surgery

Research in this area oers varied recommendations,

reecting the complex nature of surgical

interventions. Some studies advocate for an

integrated approach, combining teledentistry with

in-person dentistry. Others propose that teledentis-

try alone can be sucient. Conversely, some research

supports in-person dentistry, particularly for oral

health education in surgical contexts.

The most common primary outcome measures

are clinical indices. However, one notable study

examines cost-eectiveness and patient satisfaction,

which oers valuable insights into the economic

and patient-centered aspects of teledentistry in

surgical settings, providing a more comprehensive

evaluation of its potential benets and challenges.

3.4. Eectiveness of teledentistry compared to in-

person dentistry

The analysis reveals that mobile health technologies

emerged as the predominant communication

method, closely followed by asynchronous tech-

niques for remote patient monitoring. Interestingly,

one study [17] combined both asynchronous

and synchronous (real-time or live interaction)

approaches, though it is worth noting that no

research employed synchronous techniques exclu-

sively.

The application of teledentistry varied across the

literature reviewed. While most studies implemented

teledentistry as a complementary tool for oral

hygiene instruction, education, and behavioral

reminders, three studies explored its potential in

dierent contexts. Specically, these studies utilized

teledentistry as an adjunct to physical exercises [19],

professional consultation [5], and behavioral therapy

[45].

3.5. Teledentistry usage according to income economy

The current review examined teledentistry adoption

across 21 nations, as illustrated in Table 3, and reveals

a distinct pattern of implementation correlated

with the economic status. High-income countries

demonstrate a well-established integration of tele-

dentistry services into their healthcare systems. The

review also identies an emerging trend in upper-

middle and lower-middle-income countries, where

teledentistry utilization is gaining momentum and

showing signicant growth. However, there were no

data on teledentistry utilization available from low-

income countries in the current review.

No. Country Income Economy* Number of Studies

1 Belgium High 1

2 Germany High 1

3 Italy High 3

4 Japan High 2

5 Netherlands High 1

6 Portugal High 1

7 Saudi Arabia High 1

8 Spain High 1

9 Taiwan High 1

10 UK High 2

11 USA High 3

12 Australia High 1

13 Korea High 1

14 Hong Kong High 1

15 Brazil Upper-middle 2

16 China Upper-middle 1

17 Iraq Upper-middle 1

18 Turkey Upper-middle 1

19 India Lower-middle 5

20 Iran Lower-middle 1

21 Parkistan Lower-middle 1

4. DISCUSSION

This systematic review reveals the potential of

teledentistry to complement and, in some cases,

better in-person dentistry in terms of ecacy and

accessibility, particularly in oral health education,

behavioral modication, and reinforcement. However, it

is not yet being utilized for tele-treatment. Orthodontics

employed teledentistry most commonly, followed

by preventive dentistry, pediatric dentistry, and oral

Tun TZ et al.

*Countries’ income economy according to the World Bank is described in

Supplementary le (S4 Table)

Table 3. Distribution of the Number of studies based on the Countries’

economic status .

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and maxillofacial surgery. Most studies found that

integrating teledentistry with in-person dentistry impro-

ved patient outcomes. Mobile health technologies

and asynchronous communication emerged as the

most common teledentistry approaches. While the

quality of the studies was good, some lacked robust

design. Teledentistry shows promise in enhancing

dental care, especially when used alongside in-person

dentistry. High-income nations have well-established

teledentistry services, while middle-income countries

are increasingly adopting these technologies. However,

there was a lack of data on teledentistry in low-income

countries.

4.1. Field of Teledentistry

Teledentistry has demonstrated applications across

dental specialties, with orthodontics emerging as

the primary eld of utilization. Research shows that

integrating teledentistry with traditional practices

signicantly enhances oral health outcomes. Digital

health technologies, including mobile applications and

SMS notications, have eectively improved patient

engagement and appointment management.

Teledentistry has proven particularly eective in

disseminating oral health education in high school

settings. Across specialties, clinical indices serve as the

primary outcome measures, often complemented by

assessments of patient knowledge, behavioral changes,

and unique evaluations such as Knowledge, Attitude,

and Practice (KAP) assessments and cost-eectiveness

analyses. This comprehensive approach provides a

more holistic understanding of teledentistry's impact,

highlighting its potential to revolutionize dental care

across various specialties.

While existing studies have predominantly focused on

teledentistry's role in health education and behavior

modication, it is high time to broaden the research

scope. Future investigations should explore its potential

in professional consultations and diagnostic processes,

areas that remain underexplored but oer signicant

potential for enhancing remote dental care delivery.

4.2. Eectiveness of Teledentistry

Teledentistry was found to be eective in improving

patient education and behavior modication across

various dental specialties. It also has the potential to

enhance professional communication and may oer

cost-eective solutions in certain scenarios. However,

the eectiveness can vary depending on the specic

application and dental specialty, highlighting the need

for continued research and evaluation in this evolving

eld.

4.2.1. Patient Education

Teledentistry has shown signicant promise in

enhancing patient education across various dental

specialties. In orthodontics and preventive dentistry,

digital health technologies such as mobile applications

and SMS notications have proven eective in disse-

minating oral health information [9,47]. Notably,

teledentistry has demonstrated ecacy in providing

oral health education within high school settings [41].

The use of these technologies allows for consistent and

accessible educational content, potentially improving

patients' understanding of their oral health needs and

treatment processes.

4.2.2. Behavior modication

The implementation of teledentistry has shown positive

results in modifying patient behaviors. Several studies

incorporated assessments of behavioral modications

as outcome measures, suggesting that teledentistry

interventions can eectively encourage better oral hy-

giene practices with positive behavioral modications

[19]. For instance, in orthodontics, mobile applications

and reminders have been associated with improved

oral hygiene among patients with xed appliances. This

indicates that teledentistry can be a valuable tool for

reinforcing positive oral health behaviors between in-

person visits.

4.2.3. Professional communication

Teledentistry has shown potential implications for

professional communication. Teledentistry is recognized

as a supervision tool connecting specialists with general

dentists to minimize referrals [9,47]. This suggests that

teledentistry can facilitate improved communication

and collaboration between dental professionals, po-

tentially leading to more ecient patient care and

reduced unnecessary referrals [17]. In elds like oral and

maxillofacial surgery, where some studies supported

an integrated approach, teledentistry likely plays a role

in enhancing communication between surgeons and

other dental professionals involved in patient care.

4.2.4. Cost-eectiveness

There is limited direct information on cost-eectiveness,

however, cost-eectiveness alongside patient satis-

faction was also assessed. This might suggest that

cost-eectiveness is an important consideration in

teledentistry implementation. We can infer that tele-

dentistry may oer cost-eective solutions in certain

scenarios, such as reducing the need for in-person

visits for routine check-ups or follow-ups, particularly in

orthodontics and preventive dentistry. However, more

research specically focused on the economic aspects

of teledentistry across dierent specialties would be

benecial.

4.3. Economic context

Teledentistry oers substantial economic benets for

the dental healthcare sector, providing potential cost

and time savings compared to traditional in-person

dentistry. This allows the management of more patients

in less time [47], facilitating quick consultations and

referrals [3], which translates into economic benets for

both dental practices and patients [3].

The adoption of teledentistry is progressing globally, but

its integration varies considerably based on a country's

economic resources and healthcare infrastructure. This

variation highlights teledentistry's potential to bridge

healthcare gaps across diverse economic landscapes.

However, the review uncovered a signicant data gap

regarding teledentistry implementation in low-income

countries, raising important questions about global

health equity.

This disparity underscores the need for further research

and exploration of opportunities for teledentistry

expansion in resource-limited settings. By addressing

these gaps, teledentistry could play a crucial role

in improving access to dental care and reducing

healthcare disparities worldwide.

Review Article

Evidence-based application of teledentistry: a systematic review

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Teledentistry oers signicant advantages on an

individual level, reducing out-of-pocket expenses and

minimizing time o work. However, its implementation

necessitates initial investments in technology-such as

intraoral cameras, imaging systems, and reliable internet

connections and training for healthcare professionals

[48-50]. While these upfront costs are substantial,

they may yield long-term economic benets through

improved eciency and expanded reach, particularly in

serving underserved populations.

Integrating teledentistry with broader healthcare

systems could further enhance economic eciencies

by reducing redundancies and improving coordinated

care. The COVID-19 pandemic has highlighted tele-

dentistry's potential to provide economic resilience

during health crises [51,52]. Although specic gures

are not provided, the study suggests that teledentistry

has the potential for positive economic impacts through

cost savings, improved eciency, and better resource

allocation in dental care delivery [5].

Achieving these economic benets, however, requires

addressing implementation challenges and carefully

balancing initial investments against long-term gains.

As teledentistry continues to evolve, its economic

impact on both individual patients and healthcare

systems at large promises to be signicant, potentially

reshaping the landscape of dental care delivery.

4.4. Evaluation of the risk of bias and limitations of this

systematic review

The quality assessment of the studies suggests that

while the eld has a solid foundation of research,

there's signicant room for improvement in research

methodologies. Most studies excelled in reporting

standards and statistical power, indicating strong

documentation practices and appropriate sample

sizes. However, specic methodological concerns

were identied in some studies, particularly regarding

external and internal validity. These issues potentially

limit the generalizability and reliability of certain

ndings.

Despite these challenges, it provides valuable insights

into teledentistry, oering a foundation for future

research. It highlights both strengths (good reporting,

sucient statistical power in many studies) and

weaknesses (lack of excellent-quality studies, some

methodological issues) in the current literature.

While this analysis provides valuable insights into the

current state of teledentistry research across various

dental specialties, there are limitations to consider,

including the lack of consideration for specialty

areas of dentistry, or specied dental treatment,

limited consideration for teledentistry approach and

the exclusion of non-English literature. To advance

the eld, future studies should focus on enhancing

methodological rigor, aiming for excellent quality

to strengthen the evidence base and improve the

applicability of teledentistry research ndings. Future

research should explore the use of teledentistry in

specic dental elds, encourage its application in

targeted treatment areas, and maintain a focus on

oral hygiene control as a top priority. Furthermore,

studies with more robust designs, larger sample sizes,

and longer follow-up periods should be conducted to

strengthen the evidence base for teledentistry.

5. CONCLUSION

Teledentistry shows promise across dental specialties,

particularly in orthodontics, for patient education and

behavior modication. It oers potential cost and time

savings but faces implementation challenges. Adoption

of teledentistry varies by each country’s income level.

Integration with traditional in-person care is benecial.

Future research should focus on long-term outcomes,

patient satisfaction, and economic impacts globally.

CONFLICT OF INTEREST

Author declare that there is no conict of interests.

AUTHOR CONTRIBUTIONS

The study framework was conceived and designed by RK and

HO (Hiroshi Ogawa). TH and BP conducted a thorough search for

scientic literature and evaluated the risk of bias, under the guidance

of RK and the assistance of TZ. The interpretation of the results was

performed by RK, TH, TZ, and HO (Hikaru Okubo). The manuscript

was written primarily by TZ, with TH‘s contributions. All authors

provided constructive feedback and contributed to the development

of the research, data synthesis, and manuscript preparation.

ACKNOWLEDGMENTS

Special thanks are extended to all the colleagues and sta from the

Division of Preventive Dentistry, Niigata University, and Mahidol

University.

Review Article

Tun TZ et al.

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Review Article

Evidence-based application of teledentistry: a systematic review

23-34

Stoma Edu J. 2024;11(1-2):

pISSN 2360-2406; eISSN 2502-0285

www.stomaeduj.com

Questions

1. What are common technologies used in teledentistry?

qa. Live video consulting;

qb. Email correspondence;

qc. Remote monitoring devices;

qd. Faxing patient records.

2. Which of the following can be considered a beneﬁt of teledentistry?

qa. Increased travel time for patients;

qb. Improved access to dental care for remote areas;

qc. Reduced need for in-person visits;

qd. Limited appointment availability.

3. What type of services can be provided through teledentistry?

qa. Orthodontic consultations;

qb. Post-operative follow-ups;

qc. Major surgical procedures;

qd. Dental cleanings.

4. In teledentistry, what is essential for patient-provider interactions?

qa. Condentiality and data privacy;

qb High-speed internet only;

qc. Mandatory in-person visits;

qd. Physical tools like dental mirrors.

Tin Zar Tun, born on April 2, 1988, in Myanmar, is a dedicated doctoral student at Niigata University, Japan, focusing on Preventive

Dentistry in the Graduate School of Medical and Dental Sciences. She has a robust research portfolio, co-authoring signicant

publications, including a systematic review on school-based oral health programs in PLOS ONE and a study on the 8020

Campaign's impact in Japan in the International Journal of Environmental Research and Public Health. Her work on teledentistry

in oral health services has gained FDI’s recognition. Recently, she investigated risks related to early childhood caries and the

eectiveness of uoride varnish in preventing dental issues. Currently, her research focuses on the oral function of older adults

in Japan, contributing valuable insights to the eld.

Tin Zar TUN

MDSc, Lecturer

Department of Oral Health Science

Graduate School of Medical and Dental Sciences

Faculty of Dentistry

Niigata University, Niigata, Japan

Department of Pediatric Dentistry

University of Dental Medicine

Yangon, Myanma

Feb;47(2):158-163. doi: 10.1111/joor.12875. Full text links Cross-

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Review Article

Tun TZ et al.

23-34