Practical Applicability of Teledentistry in Pediatric Patients Amidst Pandemic : A Narrative Review

The coronavirus disease-2019 (COVID-19) pandemic has imposed a situation where all healthcare facilities except emergency services remain suspended. These times generated the necessity for the implementation of a healthcare delivery system that can be accessed digitally and, thus, benefit the majority of children as well as healthcare professionals. This review aims to propose a sound model of less technique sensitive, safe and handy strategies for dental traumatic injuries, endodontic and restorative concerns, and orthodontic urgencies until complete clinical help can be sought. Five hundred thirty articles were obtained from the PubMed, Google Scholar, Embase, Lilacs, and Cochrane databases published from 2011 to 2021. Nineteen articles that described teledentistry in the COVID-19 era were included. Teledentistry can serve as a vital patient management strategy that can aid in triaging urgent and elective patient treatment needs, ultimately easing the burden of clinics and at the same time providing a safer means of consultation.


INTRODUCTION
Dentistry has been considered as the most susceptible profession to get affected by the COVID-19 pandemic, as it involves close inspection, examination, diagnosis, and therapeutic interventions around the naso-oropharyngeal region (1). This enormously aggressive novel coronavirus SARS CoV-2, whose epicenter was Hubei province in China, was declared as a health emergency of global concern by the World Health Organization (WHO) on January 30, 2020 (2). Around the world, even after 1 year, people are still experiencing suspension of ongoing dental practices except for addressing emergent needs (3)(4)(5). A rising number of pediatric cases of COVID-19 infection with greater severity and higher risk of transmission have been seen in the second wave of the pandemic (6,7). This has made it imperative for pediatric dentists to be vigilant in triaging, assessing, and managing patients.
During these difficult times, adapting a telehealth model has been the most sound approach practiced by all nations to manage patients presenting with health problems during lockdown and otherwise. Advisories also focus on managing the majority of patients affected by COVID-19 within the home under the supervision of a treating doctor via telehealth (8). In dentistry, this approach has been proven to be successful, as it satisfies social distancing norms and allows halting the transmission of the virus to contain its spread. Teledentistry has been defined by Cook in 1997 as "the practice of using video-conferencing technologies to diagnose and advice about treatment over a distance" (9,10). Teledentistry, a form of telehealth comprising of a synergism between telecommunications and dentistry that involves the exchange of clinical derived information and relevant images for consultation and treatment planning.
The concept has proven to be a boon for the continuous delivery of necessary healthcare services during difficult situations of the pandemic (11). Innovations in the form of mobile applications and other technical developments have eased the learning and referral protocol necessary to minimize direct contact between patients and doctors.

METHODOLOGY
An electronic search from databases of PubMed, Google Scholar, Embase, Lilacs, and Cochrane was conducted for articles published from 2011 to June 2021. The use of MeSH terms "teledentistry", "teledentistry" AND "COVID-19" yielded a total of 530 articles (Pubmed: 256, Google scholar: 270, and Embase via Cochrane: 2) out of which 211 duplicates and 5 non-English publications were removed. Screening of the remaining 314 articles was performed based on title and abstract, and the articles were sought for retrieval. Full texts of only 147 articles were retrieved and screened for further eligibility. Articles published as reviews, systematic reviews, meta-analysis, observational studies, and randomized clinical trials were included while those published as case reports, books or documents, and conference proceedings were excluded. The exclusion was also made after screening based on relevance to dentistry, pediatric or general dentistry, triaging of patients, guidelines, protocol, and reviews from clinical experience. Out of the 147 articles, 19 that described a practical implementation of teledentistry service in the COVID-19 era were selected for the review (3-5, 8, 11-25). Refer to the flowchart in Supplementary Figure 1.

Two-Way Interactive or Real-Time Consultation/ Synchronous
Real-time consultation caters to video conferencing between a dentist and a patient with simultaneous exchange of information, medical history, and reports in order to reach a diagnosis within the same appointment. It also aids in the prompt exchange of information and reporting with a peer dentist or specialist. Two-way interactive technology allows procuring live images or sound occurring in an originating site to a person in a remote or distant site (26-31).

Store and Forward Teledentistry/Asynchronous
Information is gathered from one location, stored, and transferred to the treating consultant in a different location. Relevant data in the form of x-rays, photographs, and scanned images are uploaded and forwarded to the consultant after screening or storing it in the system. This system is beneficial for consulting a specialist/team from a different place/city/country before referring or managing the patient. The data can be used to educate colleagues after obtaining a prior consent. A pattern of asynchronous consultation is also available on many webpages for fetching a potential diagnosis by entering serology or pathology reports (30,31).

Remote Monitoring of Patient
Information on health and other medical data are transmitted from one location to another via electronic media for healthcare and supportive management.

Mobile Health (mHealth)
The use of mobile communication devices to support public health practice and education by using devices such as cell phones, tablets, computers, and personal digital assistants (PDAs).

Telehealthcare Model
Teletriaging Categorizing patients based on the urgency of treatment can be managed by teletriage. The dental team or front office can characterize if the case of a patient is elective or emergent. Emergent cases can be prioritized, and elective cases can be scheduled at a convenient time for teleconsultation, and appointments can be postponed to a more appropriate time (12). "Forward triage" helps to reduce the workload of a caregiver by managing non-emergent patients before they visit a hospital (32,33). It foresees any crisis that can occur and prevents unnecessary movements in times of pandemic.

Teleconsultation
Interactive consultation with a clinician by telephonic or video conferencing is the prime component of the telehealth model. Consultation with a specialist can also be included if the software allows multiple participants at a time. Exchange of chief complaint, medical history, recent and previous laboratory reports, extraoral photographs, intraoral photographs, dental cast photographs, and radiographs, and examination by virtual appointments comprises a teleconsultation.

Telediagnosis
Analysis of collected information in teleconsultation leads to formulation of a diagnosis. The appropriate diagnosis and devised treatment plan are projected to the patient. Efforts were made in the past by Haron et al. to develop "Mobile Mouth Screening Anywhere (MeMoSA R )" for detection of oral cancer (34). Limited access to specialist has also lead to the development of tablet based mobile microscope (Cellscope Device) as an adjust to oral cancer screening (35).

Telemonitoring
Follow-ups and routine checkups in dentistry have always been of less priority among patients. Monitoring of postoperative cases with the help of telecommunication can be effectively carried out. Taking the help from scheduled telephonic calls, video conferencing, or merely by filling e-forms about resolution of symptoms can pave the way for sound dental health and can anticipate any treatment failure to occur (36).

Applicability in Pediatric Dentistry
The American Academy of Pediatric Dentistry (AAPD) recognizes COVID-19 as an ongoing community and global problem with ever increasing number of cases among children and have, thereby, added a COVID-19 resource page in the recent reference manual, AAPD 2020-2021 namely "Re-emergence A Report on Pediatric Dental Practice Re-entry into Practice During the COVID-19 Pandemic" (13), also holds the statement for parent-FAQ (37). It also highlights the implementation of public health initiatives and the impact on oral healthcare delivery during the suspension of dental practice. Adoption of teledentistry in daily practice: 1. Conduction of regular virtual continuous dental education programs and webinars for dentists to appraise various recent software and technological platforms as a medium for practicing teledentistry. 2. Dissemination of approaches for adequate management by dentists can be delivered by hospital-based software with stepwise triaging of patients. The hospital-based software can also be converted into a self-help application with which patients can direct themselves according to their chief complaint and acquire help from a specialist by scheduling a call or initiating a conversation. Another approach of providing management options can be applicable in private dental practices where patients can talk to their treating doctors directly for help.
Pediatric patients may have a variety of treatment needs that requires definitive operative, endodontic, orthodontic, or surgical intervention in a dental clinic/hospital. We propose a model of teledentistry-assisted management of pediatric dental problems during the COVID-19 pandemic that can be augmented with video-based and live teleconsultation demonstrations in order to minimize the need for dental clinic visits. It includes at-home recommendations for non-emergency concerns that can be disseminated via teleconsultation mode for parents and caregivers. The main aim of this approach is to provide help during the pandemic when patients are unable to seek definitive treatment at the professional level because of the risk of infection, overburdened hospitals, and unavailability of functioning dental offices during lockdowns. The proposed specific problemoriented management model is described in Tables 1, 2. These tables describe proposed advice and possible modified management based on established guidelines. It must not replace the definitive treatment required for a patient in a dental clinic that involves thorough clinical examination and adjunctive tests for accurate diagnosis and treatment plan (14,(38)(39)(40)(41)(42)(43)(44)(45)(46)(47).

Recent Evidence of Teledentistry
As the dynamics of the pandemic are changing with time, the acquisition of updated knowledge of the usage and practical applications as well as challenges of teledentistry is important before designing any robust model of action. According to a survey by Dusseja et al. almost 70.7% of respondents were unwilling to visit dental clinics during the COVID-19 pandemic, and 80.5% of the participants were in favor of teledentistry to resolve their dental problems. Out of them, 58% of the responders received prescriptions via WhatsApp, 35% through telephone, 5% through video call, and 2% via e-mail and other means (17). Similarly, in a study by Davies et al. findings show that over 50% of photographic referrals resulted in either advice or antibiotics being prescribed, without the need for face-to-face contact. Over 70% of the images received during the study period were related to children aged 10 and under, and the majority related to swelling, pain, and dental trauma (18). Furthermore, a survey by Statista reports that 97% of those between the ages of 16 and 54 yr now own a smartphone with the capability to take photographs and send email (48).
In a survey by Rahman et al., patient satisfaction was evaluated along with ease of use, effectivity in accessing clinical services, and reliability of the teledentistry system; 94% of the respondents were satisfied with telephonic consultation and willing to utilize it in the future. Majority of the respondents were able to express themselves satisfactorily and clearly (19). A recent study from Google interest trends on self-medication during the COVID-19 pandemic depicted an increase in the number of searches regarding self-medication, which indicates the need to reach out to the population in different ways, one of which can be through teledentistry, as reported by Sen Tunc et al. (20).
A few more acceptance-oriented studies have achieved good responses with teledentistry consultation for pain as well as for monitoring and follow-ups. Teledentistry has been beneficial in various fields, such as orthodontics, maxillofacial surgery, and pediatric dentistry (21)(22)(23).
Barriers in the Use of Teledentistry

SUMMARY
Telemedicine has been widely used in the COVID-19 pandemic. Dentistry in the newer times does not only rely on technological advancements in terms of armamentarium and instruments but also ways to reach out to patients using convenient and advanced modes of communication media that include teleconsultation support anytime and anywhere as well as internet-based social media platforms for creating health awareness and disseminating valuable information to patients during times of crisis. Teledentistry can, therefore, serve as a vital patient management strategy that aids in triaging urgent and elective patient treatment needs, ultimately easing the burden of clinics and at the same time providing a safer means of consultation.

AUTHOR CONTRIBUTIONS
MG, TN, AS, SC, AM, SS, and PJ organized database, wrote first draft, sections of the manuscript, conception, and design of the study. All authors contributed to the manuscript revision, read, and approved the submitted version.