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www.nature.com/bdjopen ARTICLE OPEN Facilitating dental disease screening program in prisoners using an intraoral camera in teledentistry 1 2 3 Charnchai Santipipat , Issarapong Kaewkamnerdpong and Nareudee Limpuangthip © The Author(s) 2023 OBJECTIVES: To facilitate dental disease screening program in prisoners by testing the diagnostic accuracy of teledentistry examination in comparison to direct oral examination by a dentist. MATERIALS AND METHODS: This crossover study comprised three phases. Phase I, prisoner health volunteers (PHVs) enrolled teledentistry training for an intraoral camera (IOC) use. Phase II, the PHV used IOC for examining dental diseases of prisoners who reported dental-related problems, and captured symptomatic areas. The PHV and dentist independently determined tentative dental treatment need, comprising dental ﬁllings, scaling, extraction, and surgical removal of impacted tooth. Phase III, another dentist performed direct oral examination of the prisoners who reported problems in phase II and determined dental treatment needs. Sensitivity, speciﬁcity, positive predictive value (PPV), and negative predictive value (NPV) were calculated, using direct oral examination by dentist as a true positive. RESULTS: Diagnostic accuracy was determined in 152 prisoners with 215 teeth. Sensitivity, speciﬁcity, PPV, and NPV of teledentistry and direct examination between two dentists were above 80%. The lowest sensitivity and speciﬁcity of teledentistry examination by the PHV were scaling and surgical removal. CONCLUSIONS: IOC use in teledentistry facilitates dentists in dental diseases screening for prisoners with acceptable diagnostic accuracy in identifying possible treatment needs. However, the imaging obtained from teledentistry is not adequate to accurately identify all dental treatment needs. BDJ Open (2023) 9:18 ; https://doi.org/10.1038/s41405-023-00145-9 INTRODUCTION ‘Good Health Good Heart’ project. The aim of this project is to Teledentistry is the use of information and communication elevate the health and welfare of prisoners to be on par with those of the public . Healthcare for prisoners focuses on improving technologies as a component of oral health care to support oral health care delivery, consultation, referral, and patient-health the health service system, disease prevention, and health professional communication and knowledge sharing . The use promotion, as well as a providing psychological health and oral of teledentistry increases oral health service accessibility, healthcare services. The two oral health strategies are; an oral decreases the human resource and ﬁnancial burden, and improves health-screening program for the prisoners that is performed by oral health of people . Teledentistry reduces inequity in oral dental personnel and prisoner health volunteers (PHVs), and health care by increasing oral healthcare accessibility during providing oral healthcare services, including oral disease unfavorable circumstances, such as the COVID-19 pandemic, and prevention, oral health promotion, and dental treatment . some restricted locations, such as remote areas, long-term care The PHV is responsible for providing health promotion, disease facilities, and prisons [3–5]. prevention, basic health support, as well as disease surveillance Due to crowded prisons circumstances with limited healthcare and screening for the prisoners and other prison staff [11, 12]. In personnel, oral health problems have been reported among Thailand, dental personnel and equipment are not generally prisoners, including dental caries, periodontal disease, and tooth available in prisons except for the Correctional Hospital located loss with dental prostheses treatment needs [6, 7]. The negative in Bangkok, which is under the jurisdiction of the Department of impact of poor oral health on the quality of life of the prisoners Corrections, Ministry of Justice. This hospital has dental has been reported . However, in Thailand, there are barriers to professionals who can provide treatment and accept referrals prisoners accessing oral healthcare because bringing them out of from prisons in Bangkok. However, due to a shortage of dental the prison is a cumbersome process, and the number of professionals in other provincial prisons, the responsibility for accompanying prison ofﬁcers is limited . providing dental treatment services falls to the public hospitals Since 2019, the Ministry of Public Health of Thailand has closest to the prison and the provincial public health ofﬁce, established and conducted a health care project to address the which are under the jurisdiction of the Ministry of Public Health oral health problems among prisoners nationwide, called the . Additionally, a dental team administers a one-day mobile 1 2 3 Sisaket Provincial Public Health Ofﬁce, Sisaket, Thailand. Department of Community Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand. Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand. email: Nareudee.L@chula.ac.th Received: 3 January 2023 Revised: 27 March 2023 Accepted: 14 April 2023 1234567890();,: C. Santipipat et al. Fig. 1 Flow diagram of the participants’ inclusion. dental service in the prison at least four times a year, which In Thailand, the PHVs were volunteered prisoners with good time allowance who were selected by the prison chief. They must be illiterate primarily focuses on tooth extractions. and graduate at least elementary level. The PHVs had to complete the 25- In addition to the obstacles of imprisonment, since the hour health training program, which included oral health knowledge and COVID-19 pandemic began, healthcare personnel have experi- practice . The PHVs are provided basic knowledge in caries risk enced more difﬁculty in gaining access to the prisons due to assessment, oral hygiene practice, food and nutrition, screening of oral rigorous disease control measures. Adopting the use of diseases and their risk factors. They have to be able to identify possible teledentistry might increase oral healthcare accessibility, and treatment needs, comprising dental ﬁllings, root canal treatment, dental improve the prisoners’ oral health and quality of life. Therefore, scaling, simple tooth extraction, and surgical removal of an impacted tooth. the objective of this study was to facilitate a teledentistry dental Dental caries detection and assessment followed the International Caries disease screening program in prisoners by testing the diagnostic Detection and Assessment System (ICDAS) , of which the score ranged from 0 to 6. Teeth with the ICDAS score 0 to 2 indicated no treatment accuracy of teledentistry examination in comparison to direct needed. Teeth with the ICDAS score 3 to 5 and patients’ complaint about oral examination by a dentist. having tooth sensitive, toothache, tooth cavity, or black discoloration indicated dental ﬁlling need. Teeth with the ICDAS score 6 and patients’ complaint about having a tooth cavity or broken tooth with severe or MATERIALS AND METHODS sudden toothache indicated dental ﬁlling, root canal treatment, or tooth The present study was a crossover design conducted in Sisaket Provincial extraction. However, since an x-ray machine is not available in the prison, it is prison and a primary healthcare setting in Sisaket province, Thailand. The not possible to use radiographic examination to differentiate whether the male-wing Sisaket Provincial prison was chosen for data collection because teeth need dental ﬁlling or root canal treatment. For the prisoners, tooth the number of prisoners and PHVs was higher than those of female wing. extraction would be the only a treatment option for the teeth with ICDAS 6 Thus, male prisoners and PHVs were eligible for study participation. The rather than root canal treatment. This is because the teeth with extensive exclusion criteria were the prisoners with a history of violent behavior and cavitation may need root canal treatment, and endodontically-treated teeth those not willing to have an oral examination by the healthcare personnel. require a prosthesis, such as a post, core, and crown, which is not a feasible The study protocol was approved by the Human Research Ethics treatment option for the prisoners due to its expense and time consumption. Committee, Sisaket provincial public health ofﬁce, Sisaket province (Ethical The criteria for dental scaling needed was adopted from the simpliﬁed number: SPPH 2022-045), and performed in accordance with the oral hygiene index . The symptomatic non-cavitated tooth with Declaration of Helsinki Ethical Principles for Medical Research Involving supragingival calculus covering more than one third, or the presence Human Subjects. All participants agreed to and signed an informed of subgingival calculus around cervical third of the tooth indicated dental consent prior to study participation. scaling needed. An impacted tooth with patients complained about having a The dental disease screening program consisted of three phases: toothache or tooth cavity, typically a third molar tooth that could not erupt Phase I: Teledentistry training program for the PHVs vertically and might be covered by soft tissue, was an indication for surgical Phase II: Dental disease screening using teledentistry removal. According to evidence-based practice developed by the American Phase III: Oral examination by the dentist and dental treatment need Association of Oral and Maxillofacial Surgeons, impacted third molars should evaluation be removed or regularly monitored for the development of disease or The phase II, teledentistry screening program, was conducted during pathology, even if they are currently asymptomatic . However, in this August and September 2022. Phase I and phase III was carried out 2 weeks study, only prisoners with dental problems were included, and all impacted before and after phase II, respectively. The ﬂow diagram for the third molars were symptomatic, indicating a need for removal. participants’ inclusion in phase II and III is shown in Fig. 1. BDJ Open (2023) 9:18 C. Santipipat et al. Phase I: Teledentistry training program for the PHVs recorded, comprising a dental ﬁlling, dental scaling, tooth extraction, Eight out of 45 male PHVs in the Sisaket Provincial prison volunteered to and the surgical removal of an impacted tooth. On the examination date, enroll in the 1-day, 3-hour ‘Teledentistry Training Program for PHVs’. The some prisoners underwent a simple tooth extraction in a mobile dental PHVs were trained for using an intraoral camera or IOC (Portable unit in the prison. The other required dental treatments were provided Waterproof HD Video USB Stomatoscope Mouth Mirror, China), which is later at the primary care clusters. an imaging tool used in this teledentistry program (Fig. 2). The IOC can capture a picture with a resolution of 2 million pixels. A light source Power of the study calculation comprising 6 light emitting diode bulbs provides 3 levels of brightness The power analysis of sample size was calculated using G*Power version with a visual acuity distance of 2–4 cm. The camera can connect with and 188.8.131.52 program based on a two-sided 95% conﬁdence interval for a single transfer data to a computer or Android smartphone via a universal serial proportion using the exact-test family. Based on an effect size of 0.17 and a bus (USB 2.0) or microcontroller (microC) that displays an image with a sample size of 157 with a prevalence of reported a dental-related problem resolution of 1600 × 1200 and 1280 × 720 pixels, respectively. While it is (observed proportion) of 0.50, a 98.6% power was achieved. possible to transfer images from the IOC using Wi-Fi or cellular connection, these systems are not available in the prison. Therefore, in this study, images from the IOC were stored and synced to the VideoLAN Client (VLC) Data analysis media player program, which is a free application available for Windows, The SPSS program version 28.0 was used for data analysis. Descriptive iOS, and Android systems. To use the IOC in the prison, the VLC program statistics was used to demonstrate the mean (±standard deviation, S.D.) was opened on a computer. After taking an intraoral photograph, the and frequency (percentage, %). For the diagnostic testing, four values were image was stored in a folder built speciﬁcally for each prisoner in the VLC calculated for teledentistry examination by the PHV and dentist: sensitivity, program. Only the assigned nurse was authorized to transfer the images speciﬁcity, positive predictive value (PPV), and negative predictive value via a Google link or Excel sheet and send them to the dentist in the (NPV). The true positive cases were identiﬁed based on a direct oral primary care cluster. examination by the dentist in the phase III. The treatment needs The PHVs were calibrated with a dentist using 30 intraoral photographs determined by the PHV using teledentistry were compared with those of that comprised dental caries and periodontal diseases, and determined the the dentist using teledentistry and the direct oral examination by the other possible treatment options. The PHV had to achieve at least a 0.80 Kappa dentist. value in agreeing with the dentist’s diagnosis prior to being permitted to perform data collection in phase II. There was only one computer that could be connected to an IOC in Sisaket Privincial prison ofﬁce. Therefore, RESULTS one trained male PHV was randomly selected by random number to In phase II, 309 male prisoners participated dental disease participate the phase II teledentistry program. screening program in teledentistry, and 157 of them who reported dental-related problems were eligible for further direct oral Phase II: Oral health and treatment need screening using examination by a dentist. However, 5 prisoners were dropped teledentistry out in phase III; 2 of them were unable to participate due to health From a total of 1621 male prisoners, 309 of them were willing to problems, and 3 prisoners with 5 intraoral photographs were participate the dental disease screening by using the teledentistry. The excluded due to the blurring images. Therefore, the study PHV performed face-to-face interviews with the prisoners. The prisoner’s participants in phase III comprised 152 male prisoners with 215 information was recorded, comprising their demographic information, symptomatic teeth. The participants’ mean age was 33.6 (±9.1) systemic diseases, and a dental-related problem. The 157 prisoners with a years old (range 19–67 years old). Table 1 demonstrates the dental-related problem pointed out the problematic areas in their oral cavity, and the PHV used an IOC to capture the potential symptomatic baseline characteristics of the participants. The major chief areas. The camera tip was covered with plastic wrap, and after each patient complaints were toothache, tooth cavity, and a broken tooth. examination, the wrap was discarded, and the IOC tip was disinfected by Representative intraoral photograph of the teeth taken by the IOC wiping it with a towelette impregnated with a disinfection solution that needed dental ﬁlling, dental scaling, simple extraction, and TM (CaviWipes ) for 3 min, wiping with a 70% alcohol solution, and the tip surgical removal are seen in Fig. 3. was covered with a new plastic wrap. The prisoner’s information and Table 2 showed the number of teeth that needed different intraoral photographs were recorded on a Google form and its link was dental treatment as diagnosed by teledentistry and direct oral connected with the dentist in the primary care cluster. examinations. The sensitivity, speciﬁcity, PPV and NPV of the After the teledentistry screening program, the PHV and a dentist teledentistry and direct oral examinations are illustrated in Table 3. independently determined the tentative dental treatment needs for each individual tooth based on the intraoral photographs and the patients’ The sensitivity and speciﬁcity of the teledentistry examinations by symptoms. The treatment needs consisted of a dental ﬁlling, dental the two dentists were above 90%, and the PPV and NPV ranged scaling, tooth extraction, and the surgical removal of an impacted tooth. The dentist also provided the initial treatment plan for each prisoner for subsequent dental treatment appointments. Table 1. Characteristics of the participants. Variables N (total = 152) % Phase III: Direct oral examination by the dentist and dental treatment need evaluation Age (years): mean (±s.d.) 33.6 (±9.1) Another dentist who did not participate in phase II performed direct oral Patient-reported symptoms (chief complaint): examinations of the prisoners who complained about having a dental- related problem. The dental treatment needs for each tooth were Toothache 58 38.2 Tooth cavity 42 27.6 Broken tooth 35 23.0 Tooth mobility 13 8.5 Tooth sensitive 3 2.0 Do not know 1 0.7 Tooth sites with the problem (total = 215 teeth): Maxillary anterior 26 12.1 Maxillary posterior 72 33.5 Mandibular anterior 6 2.8 Mandibular posterior 111 51.6 Fig. 2 The intraoral camera used in teledentistry. BDJ Open (2023) 9:18 C. Santipipat et al. Fig. 3 Intraoral photograph taken by intraoral camera. The photographs indicated a treatment need for dental ﬁlling (a1–a2), simple extraction (b1–b2), dental scaling (c1–c2), and surgical removal of impacted tooth (d1–d2), presented alongside the corresponding ICDAS table and the recommended dental treatment need. RCT, root canal treatment. easy to maintain. The IOC has been used for patient-dentist Table 2. The number of teeth that need different dental treatments communication [5, 22], oral examination [17, 18], screening oral determined by teledentistry and oral examinations (N = 215). cancer lesions , and identifying dental diseases and soft tissue conditions [21, 24]. Previous studies have found that the IOC is a Dental treatment Teledentistry Direct oral valid and reliable tool for screening oral diseases, such as dental need examination examination caries  and oral cancer , compared with a direct oral by 2nd dentist by PHV by 1st dentist examination. We found that the IOC used in the present teledentistry demonstrated acceptable diagnostic accuracy in Dental ﬁlling 78 38 35 determining the prisoners’ dental treatment needs compared with Dental scaling 5 9 6 a direct oral examination. Simple extraction 127 159 165 Although the teledentistry and direct oral examinations by the Surgical removal of 59 9 dentists were highly consistent, some disagreements existed impacted tooth between the teledentistry examination ﬁndings by the PHV and the direct oral examination by the dentist. Approximately 50% PPV for a dental ﬁlling and NPV for a simple tooth extraction were from 81.8%–100.0% (Supplementary Tables). In addition, the demonstrated when comparing the teledentistry examination by sensitivity and speciﬁcity of the teledentistry examinations by the PHV and the direct oral examination by the dentist. This the PHV ranged from 33.3–99.0% with the lowest percentage ﬁnding might be because the PHV underestimated the treatment found for dental scaling and surgical tooth removal. The PPV for needs for dental pulp lesions. In some teeth with extensive dental requiring a dental ﬁlling, dental scaling, and surgical tooth caries, the PHV evaluated them as requiring a dental ﬁlling, removal ranged from 40–60%, whereas the lowest NPV was seen however, the dentist determined that they required simple tooth for simple tooth extractions. extraction. Clinically, some extensive dental caries teeth may undergo root canal treatment, and prosthetic rehabilitation, however for the prisoners, this treatment option is not available DISCUSSION because several clinical appointments outside the prison are Our ﬁndings demonstrated high sensitivity, speciﬁcity, PPV and required. Therefore, in addition to the IOC resolution in providing NPV in determining the dental treatment needs between two a distinct intraoral photograph, the treatment need decision dentists using teledentistry and direct oral examination. However, depends on the clinical experience of the healthcare personnel to these values were relatively low when comparing the teledentistry decide on the optimal treatment option in a speciﬁc situation. Our examination by the PHV and direct oral examination by the results suggest that the PHVs may need further training and dentist. The ﬁrst study using oral teleconsultation in a prison was clinical experience to make a more accurate treatment decision. performed by Giraudeau et al.  and several studies have utilized The 33.3% sensitivity of the teledentistry examination of the the IOC in teletedentistry for oral examination of prisoners dental scaling need indicated 66.6% false negative results, and its [5, 17, 18]. However, to our knowledge, our study is the ﬁrst to PPV was only 40.0%. This relatively high amount of inconsistency assess the validity, regarding sensitivity and speciﬁcity, of using was because gingivitis is not a clearly observed lesion, and teledentistry for dental disease screening in comparison to the gingival bleeding or inﬂammation cannot be clearly identiﬁed direct oral examination by a dentist. from only an intraoral photograph. The PHV, therefore, made their Several imaging tools have been used in teledentistry, including treatment need decision based on the patient’s complaint of an intraoral scanner , digital cameras, smartphone cameras, dental pain and misjudged them as a dental ﬁlling need. and an IOC [20, 21]. In the present teledentistry program, the IOC Therefore, in case where the prisoner has a dental compliant was used due to its low cost, being convenient to transport, and but demonstrates normal tooth structure, additional information BDJ Open (2023) 9:18 C. Santipipat et al. Table 3. Diagnostic accuracy testing between the teledentistry and direct oral examinations. Teledentistry examination Sensitivity (%) Speciﬁcity (%) PPV (%) NPV (%) PHV: Dental ﬁlling 97.1 81.1 50.0 99.3 Dental scaling 33.3 98.5 40.0 98.1 Simple extraction 75.8 86.0 94.7 51.8 Surgical removal of impacted tooth 33.3 99.0 60.0 97.1 Dentist: Dental ﬁlling 97.1 97.2 89.5 99.4 Dental scaling 100.0 100.0 100.0 100.0 Simple extraction 93.9 98.0 99.4 83.1 Surgical removal of impacted tooth 100.0 98.6 81.8 100.0 should be included, such as bleeding on probing and calculus units. Furthermore, although teledentistry cannot completely formation. A real-time teledentistry examination between the PHV replace traditional face-to-face oral health care and dental onsite and the dentist online might be used to increase the treatment, it can be used for making a tentative diagnosis and diagnostic accuracy of the dental treatment needs. treatment planning. There were some inconsistencies between the direct oral and For further studies, using multiple PHVs would be further teledentistry examinations by the two dentists, particularly about required when the oral health screening is conducted in a larger whether a simple extraction or surgical removal was needed. sample size. Other periodontal health indicators, including Some retained roots were determined as having a simple probing depth and intraoral radiographs might be collected to extraction need based on the teledentistry examination, however, provide a more accurate diagnosis and treatment need determi- the direct oral examination indicated that they required surgical nation. Using the IOC to record a video for additional information, removal. Some restorable teeth were determined as having for a such as tooth mobility and gingival bleeding may be required to dental ﬁlling need, however, the direct oral examination found increase diagnostic accuracy of dental treatment need. high tooth mobility, which requires extraction. These ﬁndings indicate that an intraoral photograph might not be adequate for CONCLUSION making an accurate diagnosis because it provides only a two- Teledentistry facilitates dentists in conducting dental diseases dimensional image. In contrast, direct oral examination provides a screening program for prisoners. Using the IOC, the dentists three-dimensional view and allows for detecting tooth movement. achieved acceptable diagnostic accuracy in identifying the Moreover, in opposing to a direct oral examination, teledentistry possible dental treatment needs compared with direct oral examination cannot accurately determine pulpal health that examination. However, the imaging obtained from teledentistry would dictate dental treatment need because diagnosis of is not adequate to accurately identify all dental treatment needs endodontic disease requires thermal and electric pulp sensibility due to limitations in making a deﬁnite diagnosis of pulp and tests . periodontal status. There are some limitations in the present study. Only one PHV was included so it is unclear whether the same accuracy level would be achieved if using multiple PHVs. Only the symptomatic DATA AVAILABILITY The raw data of this study will be provided upon request to the corresponding areas were investigated which limits the generalizability and author. validity of the results as it decreases the chance of false positives. Also, recall bias from the prisoner-report symptoms or problems could occur, resulting in underestimation of the disease pre- REFERENCES valence. Some information, including radiographic examination 1. 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