Abstract
Background:
Teledentistry has emerged as a promising approach to improve access to and the quality of oral health care. However, its integration into dental education and practice remains limited. Notably, there is a lack of research in the Canadian literature regarding dental students’ perspectives on teledentistry. In this study, we aimed to explore perceptions, experiences and training needs of undergraduate dental students towards teledentistry implementation in Canadian dental schools.
Methods
This cross-sectional study was conducted from October 2022 to July 2023. We invited undergraduate students enrolled in the third or fourth year of study at 1 of 5 dental schools in 3 provinces to participate in the study. Data were collected through a bilingual, online, self-administered, closed-ended questionnaire. Descriptive analyses were conducted to identify key conditions for the successful implementation of teledentistry into the curricula, from the perspective of undergraduate dental students.
Results:
The survey was distributed to 585 people, of whom 43 (7.4%) completed the entire questionnaire, including questions on sociodemographic characteristics; an additional 3 respondents submitted partial responses. Of the 43 respondents with complete responses, about half were 25 to 29 years of age (51% [22/43]), female (53% [23/43]) and in their third year of the dental program (63% [27/43]). Eight of these 43 participants (19%) self-identified as members of minority groups. Nearly all the respondents (98% [43/44]) expressed a lack of awareness regarding teledentistry guidance publications during the COVID-19 pandemic. Most of the respondents expressed a positive perception of incorporating teledentistry into the existing curriculum (81% [35/43]) and during clerkships (86% [38/44]).
Conclusions:
To our knowledge, this study is the first to explore the attitudes, experiences and needs related to implementing teledentistry of undergraduate dental students in Canada. Despite positive attitudes, participants reported limited knowledge of and experience with teledentistry. Although this study involved participants from only 3 provinces, these insights may inform decision-makers who are considering the integration of teledentistry into dental curricula.
Keywords
Attitude, awareness, practices, dental students, dental schools, teledentistry
Introduction
Teledentistry refers to any remote interaction involving oral health care providers, either among themselves or with other health care providers, patients and/or caregivers.1,2 This remote interaction is accomplished through any form of information or communication technology and includes synchronous (e.g., live virtual consultation) and/or asynchronous (e.g., store-forward, remote patient monitoring and mobile oral health) modalities.1,2 The evidence suggests that teledentistry is a reliable approach to overcome geographic, social and cultural barriers to accessing oral health care, improving patients’ outcomes and maximizing the quality of care, while promoting high-value care.3-8
However, the integration of digital technologies, including teledentistry, into dental practices has been slow,9 which highlights the importance of better understanding the perspectives of future dentists regarding its implementation. Studies from other countries have reported inconsistent levels of knowledge about teledentistry among dental students, ranging from relatively high10-12 to moderate13 and very low.14 In addition, dental students have reported various barriers, including the need for appropriate infrastructure, as well as their own lack of technical skills, low awareness and interest, and fear of legal issues.10,11,13-15 One of the major challenges identified in the literature is the lack of education and training on teledentistry in dental schools.14,16,17 The positive impacts of training include decreasing discomfort, boosting confidence and enhancing the readiness to adopt teledentistry.15,18 Didactic education, hands-on practice and continuing education programs with workshops are the most common strategies for integrating teledentistry into the dental curricula.14,19 In numerous studies, students have expressed their intention to use teledentistry,12,14 as well as positive attitudes toward its potential to improve access to care and to enhance dental and oral hygiene education.11,14,20 In addition, dental students have recognized the role of teledentistry in facilitating better interactions among dentists, supporting both communication with patients and patient monitoring, reducing unnecessary travel, lowering the costs of dental practice (e.g., through optimal use of dental equipment, reduction of chairside time, and performance of patient management and consultations that do not require the physical presence of both parties) and saving time.11,14,20-22
There is still a notable gap in the literature on teledentistry in Canada, specifically regarding the perspectives of dental students. Understanding the perspectives and needs of the next generation of dentists will help in effectively integrating teledentistry education into Canadian dental curricula. Teledentistry education and training are valued in terms of equipping oral health professionals with the skills and knowledge to promote its uptake and to improve the quality of delivery of oral health care services.14,16,17,19 The overall aim of this study was to explore undergraduate dental students’ perceptions, experiences and training needs in relation to integrating teledentistry in Canadian dental schools. The specific objectives were to explore the perspectives and attitudes of dental students regarding teledentistry, to describe their experiences and practices in using teledentistry, and to identify their perceived training needs for adopting teledentistry.
Methods
Study design, settings and participants
This study received ethics approval from the institutional review board (eRAP/Info-Ed file number: 22-03-052). This cross-sectional descriptive study, conducted from October 2022 to July 2023, was an integral component of a comprehensive project exploring dental students’ perspectives on the integration of teledentistry into the dental curriculum. In reporting this study, we followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).23
All dental students in their third year or above at 1 of 5 dental schools (Université Laval, Université de Montréal, McGill University, University of Saskatchewan and Dalhousie University) across 3 Canadian provinces were invited to participate in this study. At 4 of these schools, the dental program spans 4 years; at the fifth school, the Université de Montréal, the program lasts 5 years. Given the exploratory nature of the study, no formal sample size calculation was undertaken.
Inclusion and exclusion criteria
Participation was limited to students in their third year or above, as these cohorts were in the clinical training portion of their studies and thus could respond to all the questions related to the scope of this study (e.g., experiences and practices). Students who had participated in the pilot phase of the survey (described below) were excluded, as awareness of teledentistry through the pilot might have influenced their perceptions regarding teledentistry implementation.
Data collection instrument
The measurement instrument was a bilingual (English and French), online, self-administered, closed-ended questionnaire. To our knowledge, no validated questionnaire was available covering all components of interest for our study. Therefore, we developed a new questionnaire based on the literature review and related theoretical frameworks, as well as the expertise of the research team.
To assess the face and content validity of the questionnaire, an initial version of the survey underwent pilot testing with a small sample of 3 students from the faculty of dental medicine and oral health sciences at McGill University. They provided their perspectives on the clarity, flow and relevance of questions, as well as the length of the questionnaire. The pilot also helped us to estimate the time needed to fill out the survey. Based on this feedback, the questionnaire underwent refinement and modification.
The final questionnaire comprised 5 sections with a total of 63 questions: perceptions about teledentistry (4 questions), current practices using teledentistry (5 questions), acceptance of teledentistry (39 questions), educational training opportunities in dental schools (7 questions) and sociodemographic information (8 questions). A manuscript reporting the results for the section on acceptance of teledentistry has already been published24; therefore, the current article focuses on the remaining 4 sections. No distinctions were made regarding different approaches to and modalities of teledentistry. The survey (which is available upon request to the publisher) consisted of multiple-choice questions and questions with binary (yes/no) answers. For 4 of the sociodemographic questions (gender, aboriginal status, visible minority and disability statuses), respondents had the option to choose “prefer not to answer.” All sociodemographic variables were included at the end of the survey.
Each student from the 5 dental schools received an email message containing a brief outline of the research objectives. The email included a hyperlink directing potential participants to an electronic questionnaire posted on the LimeSurvey website, a platform designed to conduct online surveys (LimeSurvey GmbH, Hamburg, Germany). Participants were required to provide consent before proceeding with the questionnaire. No incentives were offered to survey respondents, and participation was voluntary. To prevent multiple entries from the same individual, access was restricted to a single entry per IP address. However, once the questionnaire was initiated, an individual could reopen it multiple times using the same IP address to complete the survey. Participants had the option to review their answers and skip questions.
Data analysis
Data were analyzed using Stata software, version 18.0 (StataCorp LLC, College Station, TX). For most of the descriptive analyses, data are reported as frequencies (with percentages). For the question regarding the goals of teledentistry, participants graded the importance of these goals on a scale; given the nature of this variable and the normal distribution of the data, results are presented as means with standard deviations.
Missing data can arise in various ways during data collection, particularly in cross-sectional studies, thus necessitating different approaches to address the issue effectively. For many variables, such as sociodemographic data, participants with complete data could not be distinguished from those with incomplete data. Therefore, missing data for these variables were assumed to be “missing completely at random.” The highest rate of missing data among participants who completed the survey was 6.5%, which was primarily observed for sociodemographic factors and for the question related to ideal training for learning teledentistry (where n = 43). Given that the rate of missing data was below the threshold of 10% recommended in the literature, we assumed that potential bias would be minimal.25 Consequently, we employed a modified complete case analysis methodology, meaning that data analysis was conducted only for information from participants with no or very few missing values. Even so, missing data were accepted for certain variables, so the tables do not have the same frequencies for all variables.
Results
Sociodemographic characteristics
The survey was sent to approximately 585 dental students across 5 dental schools in Quebec, Saskatchewan and Nova Scotia. Of this total, 88 students (15.0%) opened the survey but did not complete it fully. Among those, 46 completed at least part of the questionnaire (participation rate = 7.9%), and 43 of them completely filled out the questionnaire (completion rate = 7.4%). However, the 3 incomplete questionnaires had sufficient data for inclusion in some of the analyses.
Table 1 reports the sociodemographic characteristics of the 43 participants with complete responses. About half of the participants (51%) were 25 to 29 years of age, and more than half were female (53%). The majority (63%) of these participants were in their third year of the dental school program and already had a bachelor’s degree. Eight participants (19%) identified themselves as members of visible minority groups.
|
Characteristic |
No. (%) of participants |
|---|---|
|
Note: CEGEP = Collège d’enseignement général et professionnel. |
|
| Age (years) | |
| < 25 | 16 (37) |
| 25–29 | 22 (51) |
| 30–39 | 5 (12) |
| Gender | |
| Male | 19 (44) |
| Female | 23 (53) |
| Prefer not to answer | 1 (2) |
| Year in dental program | |
| Third | 27 (63) |
| Fourth or fifth | 16 (37) |
| Highest level of education (before starting dental program) | |
| CEGEP/college or lower | 8 (19) |
| Bachelor’s degree | 27 (63) |
| Master’s degree | 8 (19) |
| Aboriginal | |
| No | 43 (100) |
| Yes | 0 (0) |
| Prefer not to answer | 0 (0) |
| Minority | |
| No | 32 (74) |
| Yes | 8 (19) |
| Prefer not to answer | 3 (7) |
| Disability | |
| No | 43 (100) |
| Yes | 0 (0) |
| Prefer not to answer | 0 (0) |
Perceptions and attitudes about using teledentistry
Table 2 presents the results regarding respondents’ attitudes toward teledentistry, based on 46 responses. The participants had positive views of teledentistry. The top 3 perceived goals of using teledentistry were facilitating patients’ access to oral health care providers (98% of respondents), enabling patients/families’ access to oral health care providers (83%) and enhancing the continuity of oral care, particularly during crises such as the COVID-19 pandemic (80%). When respondents ranked the importance of potential goals of teledentistry, facilitating patients’ access to oral health providers had the highest ranking (mean 2.9, standard deviation 0.4).
|
Attitudes, by category |
No. (%) of participants |
|---|---|
|
Note: SD = standard deviation. |
|
| Main goals of teledentistry | |
| To facilitate patients’ access to oral health providers | 45 (98) |
| To facilitate patients/families’ access to oral health providers | 38 (83) |
| To improve the continuity of oral health care (e.g., during the COVID-19 pandemic) | 37 (80) |
| To be a potential solution for shortage of oral health providers’ | 32 (70) |
| To facilitate oral health providers’ access to patients | 29 (63) |
| To facilitate communication and coordination of care among members of a care team | 28 (61) |
| To facilitate communication between oral health providers | 28 (61) |
| To facilitate access to other health care providers | 19 (41) |
| To reduce oral health providers’ professional isolation | 13 (28) |
| To increase oral health providers’ income | 8 (17) |
| Most current uses of teledentistry | |
| Screening | 41 (89) |
| Patients’ follow-up | 39 (85) |
| Triage of patient needs | 36 (78) |
| Oral health promotion/education | 33 (72) |
| Referrals | 30 (65) |
| Diagnosis of oral emergencies | 30 (65) |
| Consultation with other health care providers | 24 (52) |
| Prevention of oral/dental diseases | 18 (39) |
| Treatment of oral/dental diseases/conditions | 11 (24) |
| Population benefiting from teledentistry | |
| People of all ages living in rural or remote areas | 34 (74) |
| People of all ages with disabilities | 25 (54) |
| Entire population | 24 (52) |
| Older adults | 23 (50) |
| Children (0–18 years of age) | 13 (28) |
| Goals of teledentistry, in order of importance (mean ± SD)b | |
| To facilitate patients’ access to oral health providers | 2.9 ± 0.4 |
| To facilitate patients/families’ access to oral health providers | 4.7 ± 9.4 |
| To facilitate communication and coordination of care among members of a care team | 4.7 ± 0.3 |
| To facilitate communication between oral health providers | 5.1 ± 0.5 |
| To facilitate oral health providers’ access to patients | 5.2 ± 0.4 |
| To increase oral health providers’ income | 5.9 ± 0.4 |
| To be a potential solution for shortage of oral health providers | 5.9 ± 0.4 |
| To facilitate access to other health care providers | 6.4 ± 0.4 |
| To improve the continuity of oral health care (e.g., during COVID-19 pandemic) | 6.9 ± 0.3 |
| To reduce oral health providers’ professional isolation | 7.2 ± 0.4 |
Among these same 46 respondents, the most current uses of teledentistry were perceived as screening (89%), patients’ follow-up (85%), triage (78%) and oral health promotion/education (72%). A substantial proportion of these dental students (74%) believed that residents in rural or remote areas, regardless of their age, would benefit the most from teledentistry.
Experiences and practices in using teledentistry
As shown in Table 3, just over one-quarter of respondents (26% [12/46]) reported having used teledentistry. More specifically, before the COVID-19 pandemic, only 11 (24%) of the 46 respondents had used teledentistry, whereas after the pandemic, 14 (30%) had done so. Phone calls represented the format most frequently used for teledentistry, both before (73% [8/11]) and after (71% [10/14]) the pandemic. Among those who reported prior experience in teledentistry adoption, general dentistry was the field in which this innovation was most commonly employed (92% [11/12]). Three-quarters of participants (75% [9/12]) used email to share resources and documents with patients. The primary purposes for which teledentistry was used were appointments (83% [10/12]), patient follow-up (75% [9/12]), triage of patients’ needs (58% [7/12]), screening (50% [6/12]) and oral health promotion/education (50% [6/12]).
|
Variable |
No. (%) of participants |
|---|---|
|
aMultiple responses allowed. |
|
| Experience using teledentistry (n = 46) | |
| Yes | 12 (26) |
| No | 34 (74) |
| Fields of dentistry in which teledentistry was useda (n = 12) | |
| General dentistry | 11 (92) |
| Periodontics | 4 (33) |
| Prosthodontics (fixed or removable) | 3 (25) |
| Orthodontics | 3 (25) |
| Endodontics | 3 (25) |
| Public health | 3 (25) |
| Oral maxillofacial surgery | 2 (17) |
| Oral medicine/pathology | 1 (8) |
| Oral radiology | 1 (8) |
| Pediatrics | 1 (8) |
| Ways in which resources or documents were shared with patients during teledentistry sessionsa (n = 12) | |
| 9 (75) | |
| Texting | 4 (33) |
| Screen-sharing | 1 (8) |
| Tasks performed during teledentistry sessionsa (n = 12) | |
| Appointments | 10 (83) |
| Patients’ follow-up | 9 (75) |
| Triage of patient needs | 7 (58) |
| Screening | 6 (50) |
| Oral health promotion/education | 6 (50) |
| Prevention of oral/dental diseases | 5 (42) |
| Diagnosis of oral emergencies | 4 (33) |
| Referrals | 3 (25) |
| Consultation with other health care providers | 2 (17) |
| Treatment of oral/dental diseases/conditions | 1 (8) |
| Prescribing | 1 (8) |
| Experience using teledentistry before COVID-19 pandemic (n = 46) | |
| Yes | 11 (24) |
| No | 35 (76) |
| Most frequently used teledentistry information and communication technology before COVID-19 pandemica (n = 11) | |
| Phone call | 8 (73) |
| Zoom | 3 (27) |
| Microsoft Teams | 1 (9) |
| Google Meet | 1 (9) |
| Experience using teledentistry after COVID-19 pandemic (n = 46) | |
| Yes | 14 (30) |
| No | 32 (70) |
| Most frequently used teledentistry information and communication technology after COVID-19 pandemica (n = 14) | |
| Phone call | 10 (71) |
| Zoom | 5 (36) |
| Microsoft Teams | 3 (21) |
| 2 (14) | |
| FaceTime | 1 (7) |
| Skype | 1 (7) |
Educational training opportunities/needs with teledentistry use
Table 4 displays respondents’ perceived needs related to successful implementation of teledentistry. Only 1 (2%) of 44 respondents was aware of the teledentistry guidance documents published by provincial and territorial dental regulatory authorities in Canada, and none had received formal training and education in teledentistry. Most respondents (86% [38/44]) identified the clinical phase as a more suitable period within the dental program for learning teledentistry compared to the preclinical phase (50% [22/44]). A large proportion of participants (81% [35/43]) considered incorporating teledentistry into existing components of the curriculum as the ideal format for training. Among instructional methods, hands-on experiences were the most…
