Teledentistry use during the COVID-19 pandemic: Perceptions and practices of Ontario dentists

doi:10.21203/rs.3.rs-2187763/v1

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Research Article

Teledentistry use during the COVID-19 pandemic: Perceptions and practices of Ontario dentists

https://doi.org/10.21203/rs.3.rs-2187763/v1

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published 04 Feb, 2023

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Background: Studies have shown the potential role of teledentistry to expedite and improve consultations, diagnosis, and treatment planning while mitigating the risk of COVID-19 transmission in dental offices. However, dental professionals' utilization of teledentistry remains suboptimal. Therefore, this study aimed to determine the perceptions and practices of teledentistry among dentists during the COVID-19 pandemic in Ontario, Canada and identify associated factors.

Methods: A cross-sectional study using an online survey was conducted among Ontario dentists in December 2021. The questionnaire inquired about socio-demographic attributes, perceptions about teledentistry use, its usage during the pandemic, and perspectives on its future application. Descriptive statistics including frequency distribution of categorical variables and univariate analysis of continuous variables were conducted first followed by Chi-square tests, to determine the association between professionals’ attributes such as age, gender, years of practice, and location of practice, and their views on teledentistry. SPSS Version 28.0 was used for statistical analysis.

Results

Overall, 456 dentists completed the survey. Majority were general dentists (91%), worked in private practices (94%), were between 55 and 64 years old (33%), and had over 16 years of professional experience (72%). The most common reason for non-utilization was a lack of interest (54%). Those who use teledentistry identified patient triage, consultation, and patient education as the three most important uses. Gender (p<0.05), type of practice (p<0.05), number of settings in which dentists practiced (p<0.05), number of resources accessed (p<0.05), and comfort levels with discussing teledentistry (p<0.05), were all found to be significantly associated with the participants’ current use of teledentistry (n=447). Type of practice (p<0.05), number of practice settings (p<0.05), number of resources accessed (p<0.05), and comfort level with discussing teledentistry (p<0.05) were significantly associated with their future willingness to use teledentistry (n=456).

Conclusions

Participants expressed mixed perceptions toward teledentistry. Despite the increased utilization during the COVID-19 pandemic, participants' lack of interest in teledentistry emerged as a barrier to its use. More education and knowledge dissemination about teledentistry's areas of application and technical aspects of use can increase interest in this tool, which may lead to a greater uptake by dental professionals.

Teledentistry

Perspectives

Practices

Barriers

COVID-19

Ontario

Canada

Teledentistry is a combination of dentistry and tele-virtual communication, which provides patient dental care at a distance [1]. This approach enables the incorporation of consultation, diagnosis, and treatment planning away from a dental office setup by utilizing communication technologies such as computers, cameras, and the internet [2]. A commonly used synchronous modality of teledentistry is “Real-Time Consultation” which involves videoconferencing technology and allows two-way interactions between a dental professional and a patient from different locations [3]. Whereas the asynchronous modality of “Store-and-Forward Method” involves forwarding remotely monitored clinical information, radiographs, photos, and lab tests to specialists for consultation and treatment planning [4, 5].

Previous studies have confirmed the utilization, application, and efficacy of teledentistry. A study reports that the implementation of communication technology could result in a substantial improvement in patient care standards [6]. Another study found that the diagnostic accuracy of teledentistry via videoconferencing was comparable to that of in-person examinations [7]. The prominent benefit of teledentistry is allowing dental professionals to treat patients remotely; thereby, reducing the need for long-distance travel [8]. In addition, it has also fostered inter-professional collaboration [2, 9]. However, the obvious limitation of teledentistry is that it cannot assist in the performance of in-clinic procedures.[8].

During the recent COVID-19 pandemic, majority of COVID-19 transmissions in dental operatories were attributed to aerosol-generating medical procedures (AGMP), which was a major concern in dental settings. [10, 11]. Other major concerns included a shortage of Personal Protective Equipment (PPE), the period in which facility requirement changes were implemented in clinics during the early stages of the pandemic, maintaining privacy, obtaining informed consent, meeting regulatory requirements for recordkeeping, and the unfamiliarity of using specific codes from fee guides [8].

Consequently, dentists in North America began using virtual modes of teledentistry to provide consultations, assess, and triage patients, provide prescriptions, and refer patients to specialists [12]. In the US, researchers sought to increase patient acceptance of mobile dentistry platform that uses intraoral cameras to provide virtual oral examinations, oral health management and treatment planning [13]. In Alberta, Canada, teledentistry was used to triage dental patients and determine whether patients’ odontogenic infections could be delayed with drug prescriptions or not during early stages of pandemic [14]. In British Columbia, Canada, teledentistry was used to establish guidelines regarding taking acceptable intraoral photography for screening and triaging of potentially malignant oral lesions in home settings as opposed to clinical settings [15].

From late 2020 to June 2022, the Royal College of Dental Surgeons of Ontario (RCDSO) has recommended that emergency cases be managed via telephone screening risk assessment in which a patient's medical history is gathered and appropriate pharmacotherapies are administered based on the initial assessment [16, 17]. Dental regulatory bodies have also been guiding dentists on using teledentistry to manage emergency dental cases [18]. Even though teledentistry is cost-effective, and efficient in reducing consultation waiting time, the integration and adoption of teledentistry in dental practices in North America and Canada has been challenging [19, 20].

According to the current literature, not fully adopting telehealth was primarily attributed to clinicians' resistance to change and a lack of technological and human resources [21, 22]. Although literature has also determined patients do have positive perspectives to using teledentistry during the COVID-19 pandemic, a gap exists in understanding the specific factors that influence dentists’ perspectives and willingness to use teledentistry [23]. Therefore, this study sought to bridge this research gap by investigating the perspectives of Ontario dentists to teledentistry before and during the COVID-19 pandemic and identify factors influencing these views. It also sought to determine the types and use of teledentistry by Ontario dentists.

Study Design and Sample

A cross-sectional study was conducted among dentists in Ontario, Canada, in December 2021. All general dentists and dental specialists licensed to practice in Ontario were eligible to participate. There are approximately 10,500 practicing dentists and 1000 dental specialists in Ontario [24, 25]. The minimum sample size for the study was computed as 384 based on an expected prevalence of 50% (no existing study on attitudes to and utilization of teledentistry in Canada), precision level of 5% and level of confidence of 95% [26]. Ethics approval for the study was obtained from the Western University Research Ethics Board (Project ID: 118715).

Survey Tool And Data Collection

An electronic survey was sent to dentists through Ontario Dental Association (ODA) listserv to approximately 9,500 members representing 90% of dentist registered in of Ontario. Prospective participants received a two-week follow-up reminder. The survey comprised of a thirty-nine-item questionnaire adapted from previous studies [27–30]. The questionnaire developed in English language, included items on participants’ sociodemographic and professional characteristics, utilization of teledentistry, current teledentistry practices, and their perceptions of teledentistry. The questionnaire included mostly close-ended and single-select questions with options for including additional information for some questions. A pilot was conducted on 15 participants and changes were made for comprehension, syntax, and clarity.

Study Variables

Socio-demographic and professional characteristics: Information included the participant’s socio-demographic (age, gender) and professional characteristics (years of experience, location of practice, population served, primary type of practice, and the number of practices settings). The age groups were categorized as < 34 years, 35–44 years, 45–54 years, 55–64 years and 65 years and above. The years of experience was grouped as < 6 years, 6–10 years, 11–15 years, and 16 years and above, and further dichotomized for bivariate analysis as 10 years or less and 11 years and above. Location of practice was categorized into three groups (major city, city/town, rural area) based on the population size of the respondents primary practice location [31]. Respondents were also asked whether they perceived their practice's neighbourhood to be low-income. They also identified the number of practices they worked in by which answers were categorized into 1, 2, or at least 3 practice settings.

Teledentistry utilization and related practices: Participants were asked to indicate their use of teledentistry for clinical practice and when they started to use it. Participants who used teledentistry were asked how often (5-point Likert scale ranging from never to always) they used it for patient triaging, dental consultations, treatment planning, and were provided with the option to include other teledentistry applications not listed. They were also asked to indicate their perceived top three most common uses of teledentistry in clinical practice from the list. Their responses were recategorized into three groups: not selected, ranked unimportant, ranked important. Participants were then asked to identify their perceived barriers to teledentistry uptake.

Perceptions to teledentistry: To assess their perceptions on teledentistry, participants were asked to rate their agreement with twelve items on a five-point Likert scale ranging from strongly agree to strongly disagree. They were further asked to indicate their likelihood of using teledentistry in the future.

Data Analysis

The data was analyzed using SPSS Version 28.0 (SPSS Inc., Chicago, IL, USA)®. Frequency distribution was generated for all variables. Bivariate analyses were conducted to identify factors associated with the participants’ current use and future use of teledentistry. The comparison variables were years of experience, gender, location of practice, type of practice and type of population served. Chi-squared test was used to test the association between variables. Statistical significance was inferred at p < 0.05.

Sociodemographic and professional characteristics of study participants

A total of 456 general dentists and dental specialists participated in the current study. Table 1 provides the socio-demographic and professional description of the study participants. Of the 456 participants, the majority identified as general dentists (90.8%), the highest proportion was between 55 and 64 years old (32.9%), and over half were males (57.0%). More than two-thirds indicated they had worked for over 16 years (71.5%), while the majority listed private practice (93.9%) as their primary workplace. Only 14.2% reported they served in a “low-income” neighborhood while 58.6% worked in a major city.

Table 1

Summary socio-demographic and professional characteristics of the study respondents
Variable	N	(%)
Professional Category General Dentist Dental Specialist	414 42	90.8 9.2
Age Category < 35 years 35–44 years 45–54 years 55–64 years 65 years and above	42 90 104 150 70	9.2 19.7 22.8 32.9 15.4
Gender Female Male Prefer not to disclose	187 260 9	41.0 57.0 2.0
Years of experience < 6 years 6–10 years 11–15 years 16 years and above	36 47 47 326	7.9 10.3 10.3 71.5
Location of practice Major City City or town Remote areas Unspecified	267 152 35 2	58.6 33.3 7.7 0.4
Type of practice Private practice Public health practice Educational institution Hospital Others	428 6 9 6 7	93.9 1.3 2.0 1.3 1.5
Neighborhood served Low income Not low income Unspecified	65 383 8	14.2 84.0 1.8
Number of practice settings 1 2 3 and above Unspecified	341 74 40 1	74.8 16.2 8.8 0.2
Total	456	100.0

Usage patterns and perspectives of teledentistry among Ontario Dentists.

Table 2 shows the prevalence and pattern of teledentistry use among Ontario dentists. A total of 225 (49.3%) respondents reported ever using teledentistry; 60 (13.1%) started before the pandemic, and 165 (36.2%) during the pandemic. Regarding the frequency of use during the pandemic (n = 390), 29.2% reported never using it, whereas a small proportion (7.2% and 1.3%) indicated using teledentistry often and always, respectively. For the participants’ who reported never using teledentistry, the most common reason was a lack of interest (54.1%). Other reasons (31.2%) included, billing problems, associates having little control over office administration, and the fact that teledentistry is ineffective. Majority of respondents (69.7%) cited the dental professional guidelines as their source of information on teledentistry, while 23.0% cited provincial health ministry guidelines. Regarding their level of comfort discussing teledentistry with patients and/or colleagues, the majority (45.6%) indicated they would neither be comfortable nor uncomfortable, while 12.6% would be very uncomfortable and 16.4% uncomfortable. Overall, 18.2% indicated they would be comfortable and 7.2% very comfortable discussing teledentistry with others.

Table 2

Teledentistry use among dental professionals
Variable	N	(%)
Use of Teledentistry (n = 456) Yes, before pandemic Yes, during pandemic No Unspecified	60 165 222 9	13.1 36.2 48.7 2.0
Teledentistry modes during the pandemic ^a (n = 225) Telephone/mobile phone Live virtual calls (Zoom, Skype etc) Capturing photos from patient’s cell phone Capturing photos via intra oral cameras Email containing patient information (photos, charts) File hosting service (e.g. dropbox, google drive) Third party platforms (e.g. Dentists online, Turnkey)	51 13 40 9 38 4 2	11.2 2.9 8.8 2.0 8.3 0.9 0.4
Reasons for not using Teledentistry (n = 218) No interest Low awareness of benefit Privacy concerns Lack of technological infrastructure Cost Other Reasons: (Billing issues, Associates who have no say, “unnecessary”)	118 64 38 35 21 68	54.1 29.3 17.4 16.1 9.6 31.2
Level of comfort discussing teledentistry (n = 390) Very comfortable Comfortable Neither comfortable nor uncomfortable Uncomfortable Very uncomfortable	28 71 178 64 49	7.2 18.2 45.6 12.6 16.4
Usage frequency during pandemic (n = 390) Always Often Sometimes Rarely Never	5 28 97 146 114	1.3 7.2 24.9 37.4 29.2
Sources of Teledentistry information (n = 456) Professional association guidelines Provincial Ministry of Health guidelines Research articles Third party sources Health blogs Other (e.g. conferences, peers, webinars) Unspecified	318 105 28 21 12 13 127	69.7 23.0 6.1 4.6 2.6 2.9 27.9
^a participants selected more than one option in response to the question prompt.

The participant’s ranking of procedures where teledentistry could be useful in clinical practice is shown in Fig. 1. Most participants (68.4%) considered patient triaging an important use for teledentistry in clinical practice followed by consultation (65.4%), educational purposes (42.5%), referrals (32.0%), treatment planning (17.3%) and others (3.7%). Procedures noted within the ‘other’ category included emergency treatment (2.0%), follow-up care (1.3%), rapport building (0.4%).

Figure 2 depicts the usage of teledentistry in clinical practice before the pandemic. Triaging was the most reported (often/always) use for teledentistry (8.2%) followed by consultations (5.9%). Other reported uses included emergency care (1.8%), follow-up after care (0.2%), information and education (0.9%), and referrals (0.4%).

Figure 3 shows the procedures for which the participants reported using teledentistry (n = 178) during the pandemic. Virtual consultation (73.0%) was the most reported procedure, followed by virtual triaging (67.4%), virtual monitoring (38.2%), virtual diagnosing (24.1%), virtual education (21.9%), and only (11.2%) reported using teledentistry for anxiety reduction.

Figure 4 shows participants’ perceptions on the efficiency and reported use of various teledentistry methods. In general, the number of participants who confirmed using the listed methods was comparatively lower than the number who indicated the method was efficient. For example, although 87.1% agreed audio calls were efficient only 30.9% reported using it during the pandemic. Similarly, while 32.7% agreed video calls were efficient, only 7.9% used it during the pandemic

Table 3 shows respondents’ opinions about teledentistry. More than half of the respondents (57.9%) agreed that teledentistry was reliable for triaging patients for care and for follow-up care (55.7%). Only 2.6% of the respondents considered technological infrastructure was a barrier to teledentistry utilization. Teledentistry was considered good for co-worker interaction by only 12.3% of the participants. Approximately 27% agreed that it increased access to care and 18.4% considered it improved access to specialist care.

Table 3

Participants’ perceptions of teledentistry in clinical practice (n = 456)
No	Statement	Strongly agree/Agree (%)	Neither agree nor disagree (%)	Strongly disagree/Disagree (%)	No response (%)
1	Teledentistry was efficient for referrals during the pandemic	116 (25.5)	172 (37.7)	102 (22.3)	66 (14.5)
2	Teledentistry has improved co-worker interaction during the pandemic	56 (12.3)	182 (39.9)	152 (33.3)	66 (14.5)
3	Teledentistry has improved communication with patients during the pandemic	105 23.0)	154 (33.8)	131 (28.7)	66 (14.5)
4	Teledentistry was effective in providing oral hygiene instructions	79 (17.3)	120 (26.3)	191 (41.9)	66 (14.5)
5	Teledentistry has improved patient access to oral health care including reducing travel time	125 (27.4)	125 (27.4)	140 (30.7)	66 (14.5)
6	Teledentistry has increased access to specialists for rural and underserved communities	84 (18.4)	197 (43.2)	109 (23.9)	66 (14.5)
7	Teledentistry should be a part of routine dental care	115 (25.2)	88 (19.3)	187 41.0)	66 (14.5)
8	Teledentistry equipment is reliable for dental consultations	181 (39.6)	109 (23.9)	91 (20.0)	75 (16.4)
9	Teledentistry equipment is reliable for triaging patients	264 (57.9)	82 (18.0)	35 (7.6)	75 (16.4)
10	Teledentistry equipment is reliable for dental treatment	59 (12.9)	102 (22.4)	220 (48.2)	75 (16.4)
11	Teledentistry equipment is reliable for patient follow-up	254 (55.7)	83 (18.2)	44 (9.6)	75 (16.4)
12	Teledentistry equipment is reliable for storing and transmitting information safely	132 (29.0)	150 (32.9)	99 (21.7)	75 (16.4)

Association between participant characteristics and current use of teledentistry.

Table 4 shows the association between the participant’s socio-demographic characteristics, professional characteristics, and current use of teledentistry. Gender, type of practice, and number of practice settings in which the dentists worked were all found to be significantly associated with the participants’ current use of teledentistry. Significantly more female dentists (p = 0.005) and more respondents who did not work in private practice (p = 0.003) adopted teledentistry during the pandemic. Teledentistry use was reported by significantly fewer dentists working in two practice settings (p = 0.033). The number of teledentistry resources accessed was also positively associated with current teledentistry use (p < 0.001). Similarly, respondents who were uncomfortable discussing teledentistry reported they were not currently using it (p < 0.001).

Table 4

**Association between respondent’s socio-demographic characteristics and current use**
Variable (N)	Current use of Teledentistry
Variable (N)	Started before pandemic (n = 60) 13.2%	Started during pandemic (n = 165) 36.2%	Not using (n = 222) 48.7%	Total (n = 447) 100.0	Chi Sq (p-value)
Professional Category General Dentist Dental specialists	13.8 9.8	37.2 34.1	49.0 56.1	90.8 9.2	0.922 (0.630)
Age Category < 35 years 35–44 years 45–54 years 55–64 years 65 years and above	4.9 20.2 10.7 12.5 15.7	46.3 37.1 35.9 38.9 28.6	48.8 42.7 53.4 48.6 55.7	9.2 19.9 23.0 32.2 15.7	10.44 (0.235)
Gender# Female Male Others	10.3 15.0 33.3	46.2 30.3 33.3	43.53.3 54.7 33.3	41.2 56.8 2.0	14.95 (0.005)*
Years of experience 0–10 years 11 years and above	12.3 13.7	44.4 35.2	43.3 51.1	18.1 81.9	2.456 (0.296)
Location of practice Major City City or town Remote areas	11.5 16.4 14.7	41.4 29.6 35.3	47.1 53.9 50	58.4 34.0 7.6	6.335 (0.175)
Type of practice Private practice Others	13.8 4.8	35.2 71.4	51.0 23.8	95.3 4.7	11.31 (0.003)*
Neighborhood served^# Low income Not low income	10.8 13.9	41.5 36.1	47.7 50.0	14.5 85.5	0.899 (0.638)
Number of practice settings^# 1 2 3 and above	12.5 16.9 15.4	33.5 46.5 48.7	54.0 36.6 35.9	75.4 15.9 8.7	10.46 (0.033)*
Number of resources accessed None 1 2 or more	14.3 10.9 16.5	18.5 43.8 43.3	67.2 45.3 40.2	26.6 45.0 28.4	27.31 (< 0.001)*
Level of comfort with discussing teledentistry^# Uncomfortable Neutral Comfortable	4.4 13.5 20.2	25.6 39.9 48.5	69.9 46.6 31.3	29.0 45.6 25.4	34.67 (< 0.001)*
*- statistically significant; # - Valid responses = 390

Predicting the future usage of teledentistry from participants’ characteristics.

Table 5 shows the association between the participant’s socio-demographic factors, professional attributes, and future teledentistry use. We found statistically significant associations between the type of practice, number of practice settings, level of comfort discussing teledentistry with others and the participants’ proposed future use of teledentistry. Dentists who are not in private practice (p = 0.001) expressed an interest in continuing or beginning to use teledentistry. Dentists working in 3 or more practices indicated interest in using teledentistry in the future (p = 0.007). Participants who reported accessing two or more resources for understanding teledentistry were more likely to use it in the future (p < 0.001). Participants who reported they felt comfortable discussing teledentistry with others were also more likely to use it in the future (p < 0.001).

Table 5

**Association between respondent’s socio-demographic characteristics and future use of teledentistry**
Variable (N)	Likelihood of future use
	Yes n = 133 (29.2%)	No n = 323 (70.8%)	Total n = 456	Chi Sq p-value
Professional Category General Dentist Dental specialists	119 (28.7) 14 (33.3)	295 (72.3) 28 (66.7)	414 (90.8) 42 (9.2)	0.388 (0.532)
Age Category < 35 years 35–44 years 45–54 years 55–64 years 65 years and above	17 (40.5) 29 (32.2) 31 (29.8) 33 (22.0) 23 (32.9)	25 (59.5) 61 (67.8) 73 (70.2) 117 (78.0) 47 (67.1)	42 (9.2) 90 (19.7) 104 (22.8) 150 (32.9) 70 (15.4)	7.22 (0.125)
Gender^b Female Male Others	62 (33.2) 67 (35.8) 4 (44.4)	125(66.8) 193 (74.2) 5 (55.5)	187 (41.0) 260 (57.0) 9 (2.0)	3.91 (0.141)
Years of experience^b (N = 455) 0–10 years 11 years and above	30 (36.6) 103 (27.6)	52 (63.4) 270 (72.4)	82 (18.0) 373 (82.0)	2.62 (0.105)
Location of practice^b (N = 454) Major City City or town Remote areas	85 (31.8) 39 (25.7) 9 (26.5)	182 (68.2) 113 (74.3) 26 (76.5)	267 (58.8) 152 (33.5) 35 (7.7)	2.02 (0.364)
Type of practice^b (N = 454) Private practice Others	120 (27.8) 13 (59.1)	312 (72.2) 9 (40.9)	432(95.1) 22 (4.9)	9.91 (< 0.001)*
Neighborhood served^b (N = 448) Low income Not low income	16 (24.6) 117 (30.5)	49 (75.4) 266 (69.5)	65 (14.5) 383 (85.5)	0.94 (0.33)
Number of practice settings^b (N = 455) 1 2 3 and above	87 (25.5) 28 (37.8) 18 (45.0)	254 (74.5) 46 (62.2) 22 (55.0)	341 (74.9) 74 (17.3) 40 (8.8)	9.74 (0.007)
Number of resources accessed None 1 2 or more	19 (14.8) 61 (30.4) 53 (41.7)	109 (85.2) 140 (69.6) 74 (58.3)	128 (28.0) 201 (44.1) 127(27.9)	22.55 (< 0.001)
Level of comfort with utilizing teledentistry^b(N = 390) Uncomfortable Neutral Comfortable	11 (9.7) 58 (32.5) 64 (58.5)	102 (90.3) 120 (67.5) 35 (35.5)	113 (29.0) 178 (45.6) 99 (25.4)	71.14 (< 0.001)
^b Non-responses excluded

The study results show that prior to the COVID-19 pandemic, the use of teledentistry among dentists in Ontario, Canada, was low, but it increased during the COVID-19 pandemic. In general, respondents had a mixed view of teledentistry. The results also show that during the pandemic, a greater number of female dentists, dentists working outside of private practice, and dentists working in a single dental office began using teledentistry. The results further indicate that dentists working outside of private practice, dentists working in three or more dental offices, dentists who reported accessing two or more teledentistry resources, and dentists who felt comfortable discussing teledentistry with patients and/or colleagues will likely use teledentistry in the future.

Approximately half of the participating dentists reported the current use of teledentistry, with majority starting during the pandemic. Similar trends in the utilization of teledentistry have been reported previously [32, 33], with widespread travel restrictions and lockdowns being a major driver of its use. In addition, the increased teledentistry use is likely due to the support of regulatory and governing bodies across Canada including RCDSO [34, 35]. In an effort to promote teledentistry, the Ontario Dental Association introduced a billing code and expanded guidelines for the use of teledentistry in private dental practise during the COVID lockdown. Despite these measures, the implementation of this code faces obstacles, including dentists' lack of awareness of teledentistry codes and the uncertainty of coverage through various insurance companies and their plans, as reported by Singhal and colleagues in 2022 [12]. This has led to a lack of clarity in the compensation process, delaying the optimal implementation of teledentistry [12].

Like previous studies, our study results showed teleconsultations, triaging, and patient monitoring were the common reasons for utilizing teledentistry during the pandemic and were of highest importance amongst our study participants [28, 36, 37]. In an Alberta study, Rabie and Figueiredo identified teledentistry as a significant triage tool. In addition to triaging, it helped reduce the backlog of dental emergencies during the initial lockdown phases, while prioritising emergency care and preventing the spread of COVID [13]. Whereas, the importance of teleconsultations and follow ups can be attributed to the convenience and efficiency. Teledentistry is a crucial tool in patient education due to its ability to reinforce patient education and hygiene instructions via multiple, reproducible, and personalized follow-ups [38]. A study by Torul and colleagues confirmed that virtual follow-ups via video calls are as reliable as the conventional face-to-face follow-ups with the ease of reduces travelling cost and time [39].

In terms of the different modes of teledentistry, audio calls were reported to be the most efficient communication method, followed by photos taken from patient’s phones and emails communications. In London, UK, Viswanathan et al. also found that a telephone review system was efficient at triaging patients efficiently, especially at the beginning of the pandemic when aerosol generated procedures were of a dire concern [40]. Whereas, in Italy, high-quality photos of simple lesions were regarded as efficient in distinguishing malignant pathologies from potentially malignant pathologies [41]. Unlike the study conducted by Estai and colleagues in Australia where emails were the most reported mode of communication, our study has indicated e-mail to be the third most efficient way of exchanging information with the main advantage of being relatively inexpensive and easy to use. [29]. Without digitalization and phone conversations, the lockdown implemented by the government would have made patient care even more challenging [42].

Our findings indicate that disinterest in teledentistry was the most significant barrier to its adoption. This finding is supported by the participants' contradictory attitudes towards teledentistry. For instance, only about a quarter of our respondents agreed that teledentistry would increase access to care, especially by eliminating travel time, indicating low awareness of teledentistry's benefits. This is an important benefit, as research indicates that teledentistry can play a crucial role in expanding access to dental care for individuals and communities. Teledentistry use could decrease the number of dental visits for patients, especially for vulnerable groups who have a high risk for complications due to COVID-19 and higher dental needs such as the immunocompromised and the elderly; hence, this could reduce the dental anxiety accompanying COVID19 [43, 44]. According to research, teledentistry also has the potential to improve continuity of care, increase preventive interventions, and most importantly, increase access to specialist care and general dentists in rural and remote communities. [45, 46] It is also reported that its capacity to provide a wide variety of preventative dental care increased the retention of healthcare workers [47].

These advantages are crucial justifications for promoting teledentistry among dentists. Thus, there is a need to increase dental practitioners' awareness of teledentistry considering their lack of interest in the topic and their ambivalent perspectives to it. More than half of the study participants utilized provincial guidelines for the use of teledentistry. Not surprisingly, respondents who had accessed more guidelines were also more likely to use teledentistry; others reported a similar trend [36]. Evidence suggests that resources such as online training modules by regulatory bodies and continuing education could be linked to successfully implementing teledentistry into routine practice [36]. Our results also identified significant associations between the type of practice setting (private VS public) and number of practices (one VS two or more) to be significantly associated with the utilization of teledentistry. Dentists who worked in private practices are less likely to use teledentistry than their counterparts. This underutilization of teledentistry in private practices could be attributed to lack of interest to invest time and resources in learning and installing new technology [32]. Promotional strategies for teledentistry should target female dentists, private practitioners, and dentists with multiple practises.

Another strategy for promoting the use of teledentistry is to incorporate it into dental curriculums. Research indicates that training undergraduate students on the integration of teleconsultation, teletriaging, and other important aspects of teledentistry could lead to reductions in clinic costs, travel time, and chair time; thereby, improving patient management [41, 48].

This study examined the attitudes and practices of dentists in Ontario, Canada, regarding teledentistry, as well identified the factors associated with these perspectives. The overall sample size is a strength of our study as we attained the estimated minimum sample size. However, the low response rate, which may have been caused by survey fatigue during the pandemic, represents a limitation. Therefore, we are cautious in assuming generalizability of the study findings [49, 50]. Nevertheless, our findings provide evidence to inform future regulatory decisions concerning the use of teledentistry.

Our results concluded that dentists in Ontario, Canada though have positive perceptions about teledentistry, they underutilize it. Participants’ characteristics associated with the willingness to use teledentistry post-pandemic include type of practice setting, number of practice settings, and number of resources accessed. The barriers associated with the underutilization of teledentistry in practice settings include lack of interest and lack of resources. Despite teledentistry being capable to improve access to oral health services and reduce disparities between rural and urban communities, more work is required to improve the clarity and comprehensiveness of federal and provincial guidelines on its integration in private practices. Furthermore, significant reforms are also needed in the dental curriculum to integrate and optimize the use of teledentistry.

AGMP - Aerosol Generating Medical Procedures

PPE - Personal Protective Equipment

RCDSO – Royal College of Dental Surgeons of Ontario

ODA – Ontario Dental Association.

The authors declare no conflict of interest. All methods were carried out in accordance with the Declaration of Helsinki.

Ethics approval and consent to participate

Ethics approval to gather and report information on human participants for the study was obtained from the Western University Research Ethics Board (Project ID: 118715). Informed consent was obtained from all participants using a letter of information and consent approved by the Western University Research Ethics Board.

Consent for publication

Not applicable.

Availability of data and materials

The dataset used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

The Schulich Dentistry Research Opportunity Program has funded the stipend for the summer student to assist with this project.

Authors’ Information

Affiliations

Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada

Rocco Cheuk, Abbas Jessani

Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada

Adeniyi Abiola

Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada

Julie Farmer, Sonica Singhal

Health Promotion, Chronic Disease and Injury Prevention Department, Public Health Ontario, Toronto, Ontario, Canada

Sonica Singhal

Contributions

A.J. is the PI of this project and supervised the summer undergraduate research student R. C in developing and executing the research. A. A. contributed to the data analysis and manuscript preparation; J. F. and S. S. contributed to the questionnaire design and manuscript preparation.

Corresponding Author

Correspondence to: Dr. Abbas Jessani

Acknowledgements

We are thankful to Royal College of Dental Surgeons of Ontario (RCDSO), for the dissemination of the survey to all the registered dentists in Ontario, Canada. To all the participants who have participated in the survey.

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No competing interests reported.

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Teledentistry use during the COVID-19 pandemic: Perceptions and practices of Ontario dentists

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