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Resuts 

The initial baseline data obtained from the visual oral health screenings in the school were compared with data obtained from the telehealth screenings for primary tooth decay, primary teeth needing extraction, and primary restored teeth (deft index), and for permanent tooth decay, permanent teeth missing due to caries and permanent restored teeth (DMFT index). Only small variations occurred between the two methods (Tables I and II). Chi-squared tests were used at p<0.05. The groups showed no statistically significant differences. 

Kappa statistics8 were applied to the data to determine agreement in excess of that expected through chance (Table III). Perfect agreement existed for the three categories of primary teeth to be extracted, permanent teeth missing and permanent teeth filled. For both the primary and permanent teeth with decay groups, the kappa statistic showed moderate agreement, and for the group in which primary teeth were to be filled, the agreement was very good. The percentage agreement between the traditional school visual screening and the telehealth screening was very close, and in those areas where variation occurred, the kappa agreement showed moderate to very good agreement.  

Overall, the screening results between the traditional and telehealth methods of performing dental screenings were similar, with no difference found in the areas of detection of primary teeth to be extracted or filled, and permanent missing teeth. 

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Discussion 

Though not new to medicine, telehealth technology has not become part of every day health care or dentistry. Technical immaturity, economic feasibility and legal considerations may be partly responsible for its restricted role. Cost-effectiveness is also an important consideration in evaluating its potential use. Capital equipment costs for the telehealth system are very high and will vary from facility to facility. The cost of the LinkCarer System, which can have many equipment configurations, can range from approximately $40,000 to $130,000. For dental screenings to be cost-effective using this system, it would likely be necessary for the telehealth infrastructure to be already present. Alberta Health is currently considering expanding the telehealth equipment to more sites within the province, which would allow a "piggyback" effect for completing dental consultation and screening services without having to purchase and install equipment solely for that purpose. If a health facility or clinic purchased telehealth equipment, then the capital costs could be passed on in the form of user fees for the clinicians or groups utilizing the equipment. 

This study showed that a number of factors contributed to the cost of each process. Both types of screenings involved a team consisting of a dental hygienist and a dental assistant. Extra personnel were required at both the school and the telehealth facility to help with getting the children to and from the screening site. Set-up time was similar in both settings. Although the telehealth screening time per child was initially a little slower, experience with the system eventually allowed for the two types of screenings to take about the same amount of time. 

There were, however, differences between the two methods that would impact on any cost-benefit analysis. The school dental screenings involved the cost and time of travel for the dental staff to go to the school. For the telehealth screenings, the costs involved transporting the children from the school to the health facility (which in this case were assumed by the school), the cost of having a trained person operating the intraoral camera (which may or may not be a person with dental training), and the cost of using the telehealth equipment. 

There was no cost to the public health dental program for utilizing the Two Hills Health Centre equipment, as both groups belong to the Lakeland Regional Health Authority. If a system were to be used on a regular basis, and the capital and transmission costs factored into any user fees, then the investment would eventually be covered. Hopefully, the individual cost of using such equipment would not be too prohibitive. Further studies are needed to investigate the very real issue of the economic viability of this technology. 

The merits of the telehealth screening method include the fact that it is a potentially mobile system that can be manipulated by trained, non-dental personnel. The telehealth system also allows for clear communication of visual and audio data over great distances, all in real time, thereby significantly reducing travel time and costs for both practitioner and patient. (It can also accommodate patient assessments, history taking, transmission of digital data, radiographs and stilled images, either in real time or on videotape for later use.) The technology could also be used for real time, pre-authorization for dental insurance benefits. 

Potential weaknesses of this method include the cost of equipment, especially in start-up cases. As well, for clinicians unaccustomed to using an intraoral camera, some preparation time and practise in visualizing the teeth and oral cavity is required. Training of the distant health care worker in the use of the intraoral camera is also necessary. It was noted, for example, that care needs to be taken during the transmission of the visual image to ensure that correct colour tone and brightness are achieved. Furthermore, if the screening is to be completed without the use of explorers, there will be an accompanying loss of detail in the data recorded as no tactile information will be transmitted. The system was found to be most effective in identifying missing and filled teeth, probably because these two areas are easily visualized and do not require tactile sense to detect. Another reason for this may be that there were very few teeth in these index categories. The percentage agreement in these categories was predominantly on sound teeth. Less agreement was observed in the detection of decay.  

No explorers were utilized in the study. It is possible that the dental hygienist was so accustomed to using an explorer for detecting decay that she found using only visual detection less definitive or reliable than detection using tactile sensation. In addition, visual detection of decay may have been hindered due to the unfamiliarity with intraoral viewing of teeth. These factors could have introduced variability in the recording of carious lesions and would have potentially decreased her intra-examiner reliability. If concern existed in a clinical setting about the loss of detailed diagnostic information as a result of not having the remote inspections completed with the use of an explorer, both digital radiographs and standard films could be easily transmitted to enhance the information being collected. 

The population pool of the study was small due to time constraints on that school day and to the fact that five children out of the 32 had lost some of their teeth, which impacted on their deft score. Their inclusion in the study would have inappropriately reduced the statistical accuracy of the telehealth screenings. In retrospect, it would have been prudent to reduce the time interval between the first and second screenings to avoid the potential for change in the deft/DMFT status as a result of exfoliation or dental treatment. 

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Conclusion 

This pilot study indicated that the data collected using the telehealth system was similar to that of the traditional, intraoral visual screenings currently completed in public health dental programs. The telehealth system enables reliable, remote observation of oral conditions such as decayed, missing and filled or extracted teeth. It is used to transmit oral images to dental hygienists, dentists or specialists in urban centres for consultation or educational purposes (for example, communication with dental students in satellite locations). Although digital imaging is becoming more widespread and available in dentistry, the use of telehealth technology in remote dental screenings will depend on the existence of telehealth equipment throughout the province. The extensive cost of establishing telehealth sites will require financial support and a utilization across a broad spectrum of health care disciplines. Although networking of this technology may require some initial cost and implementation time, once fully developed, the system could offer a simple and reliable alternative to remote dental care.  

Acknowledgment: Special recognition and thanks go to the following dental hygienists and assistants for their invaluable assistance in carrying out this project: Shari Holland, Cory McQuaig, Patrick Miklos, Jennifer Parsons, Afae Rodwell, Sandy Tillotson and Sherry Kokotailo. 

The cooperation and support of the Lakeland Regional Health Authority, Two Hills Health Care Centre and Two Hills Elementary School was greatly appreciated. 

Dr. Patterson is director of continuing dental education in the Department of Oral Health Sciences, University of Alberta, and director of the Dental Public Health Centre, University of Alberta. 

Dr. Botchway is a clinical assistant professor in the Department of Oral Health Sciences, University of Alberta, and is a member of the Dental Public Health Centre, University of Alberta. 

Reprint requests to: Dr. S. Patterson, Department of Oral Health Sciences, Dentistry/Pharmacy Centre, University of Alberta, Edmonton, AB T6G 2N8. 

The authors have no declared financial interest in any company manufacturing the types of products mentioned in this article. 

References 

1. Alberta Telehealth Project Planning Team. Whither telehealth: How can a province-wide system work in Alberta? The Alberta Telehealth Project _ Working Document. Sept. 1996. 

2. Sanders JH, Tedesco FJ. Telemedicine: Bringing medical care to isolated communities. J Med Assoc Ga 1993; 87:237-41. 

3. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA 1995; 273:483-7. 

4. Gitlin JN. Teleradiology. Radiol Clin North Am 1986; 24:55-68. 

5. Tyndall DA, Boyd KS, Matterson SR, Dove SB. Video-based teleradiology for intraosseous lesions. A receiver operating characteristic analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80:599-603. 

6. Dzierzka J. Computer imaging: Its practical application. JADA 1991; 122:41-4. 

7. Edgington EM, Pimlott JFL. Telehealth technology: A new medium for in-service education. Probe 1998; 32:97-101. 

8. Altman DG. Practical statistics for medical research. Chapman and Hall, London, 1991. 

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