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Amid COVID-19, and other possible future infectious disease pandemics, dentistry needs to consider modified dental examination regimens that render quality care, are cost effective, and ensure the safety of patients and dental health care personnel (DHCP). Traditional dental examinations, which number more than 300 million per year in the United States, rely on person-to-person tactile examinations, pose challenges to infection control, and consume large quantities of advanced-level personal protective equipment (PPE). Therefore, our long-term goal is to develop an innovative mobile dentistry (mDent) model that takes these issues into account. This model supplements the traditional dental practice with virtual visits, supported by mobile devices such as mobile telephones, tablets, and wireless infrastructure. The mDent model leverages the advantages of digital mobile health (mHealth) tools such as intraoral cameras to deliver virtual oral examinations, treatment planning, and interactive oral health management, on a broad population basis. Conversion of the traditional dental examinations to mDent virtual examinations builds upon (1) the reliability of teledentistry, which uses intraoral photos and live videos to make diagnostic decisions, and (2) rapid advancement in mHealth tool utilization.
In this pilot project, we designed a 2-stage implementation study to assess 2 critical components of the mDent model: virtual hygiene examination (eHygiene) and patient self-taken intraoral photos (SELFIE). Our specific aims are to (1) assess the acceptance and barriers of mDent eHygiene among patients and DHCP, (2) assess the economic impact of mDent eHygiene, and (3) assess the patient’s capability to generate intraoral photos using mHealth tools (exploratory aim, SELFIE).
This study will access the rich resources of the National Dental Practice-Based Research Network to recruit 12 dentists, 12 hygienists, and 144 patients from 12 practices. For aims 1 and 2, we will use role-specific questionnaires to collect quantitative data on eHygiene acceptance and economic impact. The questionnaire components include participant characteristics, the System Usability Scale, a dentist-patient communication scale, practice operation cost, and patient opportunity cost. We will further conduct a series of iterative qualitative research activities using individual interviews to further elicit feedback and suggestion for changes to the mDent eHygiene model. For aim 3, we will use mixed methods (quantitative and qualitative) to assess the patient’s capability of taking intraoral photos, by analyzing obtained photos and recorded videos.
The study is supported by the US National Institute of Dental and Craniofacial Research. This study received “single” institutional review board approval in August 2021. Data collection and analysis are expected to conclude by December 2021 and March 2022, respectively.
The study results will inform the logistics of conducting virtual dental examinations and empowering patients with mHealth tools, providing better safety and preserving PPE amid the COVID-19 and possible future pandemics.
PRR1-10.2196/32345
Amid the COVID-19 pandemic, dental health care personnel (DHCP) are at great risk of contracting the SARS-CoV-2 virus due to their close physical proximity to their patients, as well as the enhanced potential for transmission of airborne viruses in the dental setting [
Aggressively converting traditional dental examinations (eg, comprehensive, limited, and hygiene recall examinations) to virtual examinations could significantly reduce the exposure risk for patients and DHCP and preserve a large volume of PPE essential to the medical and dental communities. According to the American Dental Association, as of 2019, 200,419 dentists were practicing dentistry in the United States, with 158,331 (79%) general dentists (GD) providing a range of examination visits on a daily basis [
In the current dental examination model (
Current and proposed mobile dentistry (mDent) model for dental examinations. PPE: personal protective equipment.
Our long-term goal is to develop an innovative mobile dentistry [
This mDent model will fully engage relevant stakeholders (patients, dental hygienists, and dentists) to conduct interactive oral health practices. The mDent model will also utilize a patient-driven mobile device to increase the accessibility of dental care. Moreover, in the era of COVID-19 risk, this remote virtual dental service model will lead to a well-planned dental service, better infection control, and reduced PPE consumption. As this eHygiene implementation study is a hypothesis-generating pilot study, our immediate objective is to assess the following 3 aims in the National Dental Practice-Based Research Network [
This study will use a 2-stage implementation study to assess the acceptance of 2 components (eHygiene and SELFIE) of the mDent eHygiene model among patients and DHCP (dentists and dental hygienists). The components are illustrated in
Specific aims, study design, and outcome measures. DPC: dentist-patient communiation; SUS: System Usability Scale.
This mDent eHygiene study will use mixed methods (quantitative and qualitative) to collect outcome measures and conduct data analysis. For details, see
Mobile dentistry (mDent) model eHygiene objectives and outcome measures.
Aims | Outcome measurements | Brief description and justification of the outcome measures |
Aim 1: assess the acceptance of and barriers to mDent eHygiene among patients and DHCPa | System Usability Scale (SUS); dentist-patient communication (DPC); theme of acceptance and barriers analyzed from individual qualitative interviews with the DHCP | The SUS instrument will be used to assess the acceptance of the mDent eHygiene approach. The SUS instrument [ |
Aim 2: assess the economic impact of mDent eHygiene | PPEc consumption and estimated cost and eHygiene chair time per patient; eHygiene virtual visit time per patient; DHCP (dentist and dental hygienist) personnel cost related to eHygiene | Studies from other groups have shown improved cost-effectiveness using virtual dental visits [ |
Aim 3: assess patients’ capability for generating intraoral photos using mHealth tools (SELFIE) | Quantity and quality of intraoral photos taken by patients, assessed by 1 dentist in the study team who will be trained for photo assessment; themes of challenges encountered by patients while taking intraoral photos themselves, by analyzing the video recordings from the SELFIE session | This objective will provide preliminary data on patient engagement with using mHealth tools, which is essential to empowering patients in the complete mDent model. |
aDHCP: dental health care personnel.
bmHealth: mobile health.
cPPE: personal protective equipment.
The mDent eHygiene study will be conducted in the Northeastern node of the National Dental Practice-Based Research Network in the United States. This mDent eHygiene study will enroll 144 patients and 24 DHCPs from 12 practices. Each practice will enroll 12 patients, 1 dentist, and 1 dental hygienist. All 144 patients and 24 DHCPs will conduct the eHygiene session (1st stage) of the study. Among enrolled patients and DHCPs, 5 patients, 5 dentists, and 5 dental hygienists will be invited for a 30-minute recorded telephone interview for a qualitative session of the eHygiene study. In addition, 12 patients will be invited to conduct a SELFIE session to evaluate their capability for taking intraoral photos by themselves, with guidance from the dental hygienist.
The dental hygienist will complete a routine hygiene visit, update x-rays, and perform a hard and soft tissue examination as part of routine clinical care. Intraoral photos of patients will be taken for research purposes following a recommended template (See
Patient self-taken intraoral photos: (A) front view taken on an iPhone X, on which gingival erythema and multiple white spots (de-calcification) are seen; (B) posterior photos taken with a Mouthwatch intraoral camera, where the upper panel includes photos of the lower left first molar and lower panel photos of the upper right first molar.
The dentist will then conduct a virtual visit with the patient lasting approximately 30 minutes at a later and suitable time within 14 days of the eHygiene intraoral photo visit, to review eHygiene findings and treatment plans.
The self-taking of intraoral photos (SELFIE session) will be piloted by 12 (1 from each practice) of the 144 study patients who complete the eHygiene session. The intraoral camera and instructional video will be given to the patient when the patient leaves the hygiene visit. During a virtual visit with the dental hygienist, the patient will use an intraoral camera while being supervised by the dental hygienist to take a series of intraoral photos of the front and posterior teeth. This virtual visit session will be recorded.
Patients will be encouraged to think-aloud [
Each participating patient, dentist, and dental hygienist will complete baseline and post-eHygiene role-specific questionnaires (see
After receiving the SUS scores from all patients and DHCPs, the study team will randomly select 15 individuals (5 patients, 5 dentists, 5 hygienists) for virtual individual interviews lasting approximately 30 minutes. These 15 individuals will include those who rated above and below the average SUS score. The questions asked during the interview will address feedback and recommendations, perceived challenges, and suggestions for improvement of the mDent eHygiene model. The interviews will be standardized using an interview guide (see
The sample size calculation for the primary outcome (eHygiene—SUS) was based on the primary outcome of the SUS score from patients. Various studies [
Dentists and dental hygienists will complete the SUS for each patient when the dentist and hygienist complete an eHygiene visit, which means each dentist and hygienist will evaluate the eHygiene model 12 times. Assuming a mean difference of 30 (SD 20) between the first and last patients evaluated by the dentists and hygienists, using a paired
Using a cluster randomized design to calculate the sample size for the primary outcome of DPC and assuming a mean difference in the patient-evaluated DPC score between the current hygiene model and the eHygiene model of 8 (SD 10), a sample size of 48 patients from 12 practices (4 per practice) will achieve 85% power, at an alpha of .05. A sample size of 144 patients will satisfy the statistical power of the DPC outcome, while considering potential dropouts.
For the sample size calculation of the tertiary outcome (SELFIE), we expect to reach data saturation [
We will calculate SUS scores for the eHygiene model (post-eHygiene SUS) as rated by patients, dentists, and dental hygienists. The SUS score from the patients and DHCPs between practices will be compared. A linear mixed effects model will be used to examine factors that influence the SUS score as perceived by patients, including patient factors (demographic, socioeconomic, education, profession, and experience with using a digital device and mHealth tools) and DHCP factors (demographic and dental practice experience), while considering the clustering effects within practices and providers. The eHygiene SUS score as rated by dentists and dental hygienists from treating the first patient through the last study patient will be compared to assess whether the DHCP-determined SUS score is associated with a learning curve.
We will calculate the DPC score as rated by patients, which assesses how well the patients understand the planned treatment and the quality of the communication between the patients and dentists who participate in eHygiene. We will use a linear mixed effects model to examine factors that influence the DPC score perceived by patients, including patient factors (demographic, socioeconomic, education, profession, and experience with using a digital device and mHealth tools), DHCP factors (demographic and dental practicing experience), and time spent on the eHygiene visit, while controlling for the clustering effects within practices and providers. We will run separate models for patients and DHCP.
Regarding qualitative data, the interviews will be standardized using interview guides, audio-recorded, transcribed, coded, and analyzed for thematic content. The audio recordings will be transcribed by the Temi (San Francisco, CA) transcription service and further verified by 2 trained research personnel. Transcribed data will be analyzed using MAXQDA software (VERBI GmbH, Berlin, Germany). The data will be coded by 2 trained coders with predetermined open codes using a codebook with a description of the coding tree. Thematic content will be further analyzed using categorizing and contextualizing strategies to understand the factors associated with acceptance of and barriers to eHygiene among patients and DHCPs.
We will conduct analysis for the following parameters: (1) PPE consumption and estimated cost and comparison between eHygiene and traditional hygiene examination models for each practice; (2) eHygiene chair time per study patient, learning curve–related fluctuations in chair time per practice, and comparisons between practices; (3) eHygiene virtual visit time and comparison between practices; and (4) DHCP (dentist and dental hygienist) personnel cost related to eHygiene in-office and virtual visits, compared with traditional hygiene examination visits.
Parameters to be evaluated include time spent on photo taking, number of photos, and readable photos by a dentist evaluator using a photo assessment from (
The “think-aloud” videos recorded during the SELFIE sessions will be reviewed by a trained study evaluator to analyze common themes of challenges patients encounter, using a SELFIE assessment form (
The study has been peer-reviewed and funded by the US National Institute of Dental and Craniofacial Research. This study received single institutional review board approval from the University of Alabama at Birmingham (#300006506) and local context review from the University of Rochester (#6077). The eHygiene study is expected to launch in August 2021. Data collection and analysis are expected to conclude by December 2021 and March 2022, respectively.
This study is innovative in several ways. First, conducting virtual dental examinations (the mDent model) using intraoral photos and x-rays is novel and potentially transformative to dental practice. Using smartphones and mobile devices to take photos of the mouth and teeth and conduct oral disease screening has been recently reported [
Successful completion of this eHygiene pilot study will provide data on the acceptance and economic impact of virtual dental examinations during eHygiene visits, which will be a test vehicle for the future mDent model. The results will inform potential immediate modification of the dental service system to provide better safety and preserve PPE amid COVID-19 and other infectious disease outbreaks and beyond.
Intraoral photo taking template.
Dentist role-specific questionnaire.
Hygienist role-specific questionnaire.
Patient role-specific questionnaire.
Qualitative interview guide.
SELFIE session intraoral images assessment form.
SELFIE session video assessment form.
dental health care personnel
dentist-patient communication
general dentist
mobile dentistry
mobile health
National Institute of Dental and Craniofacial Research
personal protective equipment
System Usability Scale
This study has been peer-reviewed and funded by National Institutes of Health grants X01DE030396, U19-DE-28717, and U01-DE-28727. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health.
JX, CM, DTK, TTW, and KF contributed to the conception; design; data acquisition, analysis, and interpretation; and drafting and critically revising the manuscript. PR, KF, TRL, LAMC, EI, MS, and the National Dental Practice-Based Research Network Collaborative Group contributed to data acquisition, data analysis, and critically revision of the manuscript. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. An internet site devoted to details about the National Dental Practice-Based Research Network is located at [
None declared.