Patient satisfaction with e-oral health care in rural and remote settings: a systematic review
Systematic Reviews volume 11, Article number: 234 (2022)
During the past decade e-oral health technology has been used to address the oral health care challenges in rural and remote settings. This review systematically evaluated the literature on patient satisfaction with e-oral health care in rural and remote communities.
The systematic review included interventional and observational studies published between 1946 and 2021, in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Global Health. Patient satisfaction with received oral health care using self-reported measures, at any time after the intervention, was the main outcome of the review. The other primary outcomes were undesirable consequences of the health care (e-health or conventional) such as diagnostic error. The secondary outcomes considered were waiting time, number of visits, travel, and the cost of oral health care. Two independent researchers assessed the risk of bias using the ROBINS-I risk of bias assessment tool for non-randomized studies.
Among 898 studies, 16 studies were included in the review. In most studies reporting patient satisfaction, all patients had shown willingness for teleconsultation for a dental problem and they were mostly satisfied due to saved travel time, saved working days, and prompt treatment onset. Most of the studies acknowledged teledentistry as a cost-effective and cost-saving method. Moreover, the teledentistry consultations showed diagnostic reliability and validity values comparable to conventional dental consultations. The majority of studies were considered level 4 and 3b, due to limited sample populations, analysis based on limited alternatives or costs, non-consistent sensitivity analysis, failure to appropriately control known confounders, and/or failure to carry out an appropriate follow-up of patients.
Available evidence indicates that e-oral health is associated with higher patient satisfaction and has been found to be an effective and reliable method for patients in rural and remote areas. Therefore, in these areas, the use of e-oral health should be encouraged. However, methodological inconsistencies in the current evidence suggest the need for long-term cohort studies and clinical trials, as well as cost analysis on e-oral health in rural settings.
Systematic review registration
The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42016039942.
Since 2018, the World Health Organization (WHO) has recommended the use of digital technologies in health care sectors under the resolution adopted by the World Health Assembly . The oral health resolution voted by the WHO Executive Board in 2021 includes digital technologies and teledentistry as a tool to translate health policy into action . According to Eysenbach’s definition, “E-Health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the internet and other related technologies” . The use of e-health and e-oral health technologies enables effective remote screening, diagnosis, faster referral from primary care to specialist services, reduced amount of travel to urban sites, and increased cost-effectiveness of health care [4,5,6]. Furthermore, e-oral health has been used as a tool for promoting oral health, preventing dental disease, and improving oral health literacy [7, 8]. It facilitates access to dental care for high-risk populations in underserved communities, such as rural and remote communities, people with special health care needs, and people with low socio-economic status [6, 8]. E-oral health also provides an opportunity to reduce overall cost and improve oral health outcomes [6, 7].
Moreover, e-health and e-oral health technologies also improve patient health care communication and remote education [9, 10]. The effectiveness of e-health has been especially acknowledged during the COVID-19 pandemic , and telemedicine and teledentistry have addressed patients’ needs during the closure of dental clinics in this period. Patient-based evaluation of health care is a source of information and a tool for empowerment for health care users . In fact, patients’ satisfaction with various dimensions of health care is a major concern in public and private health care sectors, and has been considered as the “voice of the customer” . Patient satisfaction is a quality care indicator reflecting patients’ experience with received health care services in terms of quality, accessibility, availability, and affordability [14,15,16,17]. Evaluation of patient’s satisfaction with health care could also reflect health care disparities especially in the context of rural and remote settings . It has been reported that patients living in rural and remote communities may be dissatisfied with oral health care and face suboptimal oral health care outcomes because of the limited number of dental professionals in these areas, as well as less access to dental care and oral health literacy related to geographical barriers [10, 18, 19]. Furthermore, professional incompetency due to the lack of specialists or peer feedback may be a source of patient dissatisfaction [19,20,21]. Given that a large number of e-health strategic plans are being developed in rural and remote areas across the world, further investigation on this topic will support policy decision-making and planning for e-oral health programs, which will lead to the improvement of oral health and oral health care in rural and remote areas. However, to our knowledge, no systematic reviews have been carried out on the effect of e-oral health technology on patient satisfaction in rural and remote settings [18, 21,22,23].
Therefore, this systematic review aimed to answer the following questions:
When compared with conventional oral health care, do e-oral health care interventions improve the satisfaction of patients in rural and remote settings with received oral health care?
Is the harmful effect of diagnostic errors made in e-oral health care interventions in patients in need of oral health care in rural and remote settings comparable to the effect of such errors in conventional oral health care?
To what extent does e-oral health care improve patient satisfaction with care in terms of reducing waiting time, number of visits, travel, and the cost of care for patients in need of oral health care in rural and remote settings, when compared to conventional oral health care?
The protocol of this systematic review was registered in PROSPERO (International Prospective Register of Systematic Reviews, registration number CRD42016039942) and was previously published . The PRISMA reporting guidelines were followed  (Additional file 1).
Information sources and search strategy
Electronic literature searches were conducted in summer 2017 and updated in February 2021 in the following databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, current issue), MEDLINE (OVID interface, 1946 onwards), EMBASE (OVID interface, 1974 onwards), and Global Health (OVID interface, 1973 onwards). As described in the published protocol, the search strategy used medical subject headings (MeSH), EMTREEs, and text words related to the field of the study (Additional file 2). It was then peer-reviewed by HH and RS and complemented by hand searching the list of references in the identified publications or relevant reviews. The searches’ procedures were adapted to all databases using the proper syntax, subject headings, and controlled vocabulary considering maximized sensitivity of the search. No language restrictions were used in the search strategies in order to maximize the sensitivity and to identify the number of publications in other languages and verify the existing risk of bias. NICE Evidence and TRIP database were searched for grey literature using subject keywords.
Inclusion and exclusion criteria
We included English and French language original research studies in the review, with a defined quantitative methodological approach (interventional or observational) including randomized clinical trials, quasi-experimental trials, longitudinal cohorts, and cross-sectional surveys. We excluded case reports, position papers, reviews, and ongoing studies .
We adopted the Eysenbach definition of e-health : any type of e-oral health technology that could address the oral health needs of participants in terms of education, consultation, screening, diagnosis, treatment, support, or any other type of application in the field of dental medicine , with no limitation in terms of the duration of the intervention and the type of stakeholders involved in the intervention. Conventional oral health care was defined as traditional approaches to oral health care including patients’ education, consultation, disease screening, diagnosis, treatment, and support, or any other type of application in the field of dental medicine .
Patient satisfaction with received oral health care using self-reported measures, at any time after the intervention, was the main outcome of the review. The other primary outcome was undesirable consequences of the health care (e-health or conventional) such as diagnostic error. The secondary outcomes considered were waiting time, number of visits, travel, and the cost of oral health care .
The identified articles from search results were transferred to EndNote software. The process of data selection and collection was pilot tested in 10% of randomly selected included articles. Cohen’s kappa test was used to assess the reviewers’ agreement on study eligibility (k = 0.878) . Two independent reviewers screened all retrieved titles and abstracts using the inclusion criteria  (HH, MA). Discrepancies between reviewers were discussed and resolved through consensus.
The reviewers independently extracted the data from the full text of the included studies by adapting the review form from Effective Practice and Organization of Care (EPOC) Resources for review authors , as a data extraction method (Additional file 3).
Risk of bias in individual studies
Two reviewers (MA, RS) independently assessed the quality of the reports and the risk of bias. For the assessment of experimental studies, the Cochrane Collaboration tool for assessing the risk of bias was used. The assessment of observational studies was performed using the ROBINS-I risk of bias assessment tool for non-randomized studies  (Additional file 4). Disagreement was resolved by consultation with a third reviewer (EE).
A narrative synthesis was conducted in line with the guidance from the Centre for Reviews and Dissemination . Text and tables summarize and explain the characteristics of the findings in the included studies. The following variables were extracted, and validation checks were performed by HH and RS to assess the accuracy of the extracted fields: (i) lead author and year of publication, (ii) target condition, (iii) study design and sample size, (iv) country and setting of the study, (v) technologies features, (vi) main result, (vii) patient satisfaction measure, and (viii) other outcomes (Table 1). In view of the significant clinical, methodological, and statistical heterogeneity among the studies identified, the data available did not permit meaningful meta-analysis to be performed. According to Haidich, “meta-analysis should be conducted when a group of studies is sufficiently homogeneous in terms of subjects involved, interventions, and outcomes to provide a meaningful summary” . Consequently, we conducted a broad narrative synthesis of the data.
The electronic search yielded a total of 898 studies from MEDLINE (n = 378), EMBASE (n = 414), COCHRANE (n = 44), and GLOBAL (n = 62). After removing duplicates, 716 studies remained for screening. The screening based on title and abstract resulted in the exclusion of 647 articles, with the main reasons for elimination being that the studies were not related to dentistry and/or did not have a quantitative design. Of the 69 potentially eligible studies, full-text screening led to a further exclusion of 53 studies, which were deemed not relevant to the study aim (Fig. 1). The excluded studies were not centered on patients but rather, they were conducted only among dental professionals and did not consider rural and remote aspects. A total of 16 studies were included in this review.
The majority of the studies were conducted between 2010 and 2019 [31,32,33,34,35,36,37,38,39,40,41,42,43,44], with only two prior studies carried out in 1998 and 2002 [29, 30]. In total, five studies were from Australia [35, 40,41,42,43], three from India [34, 39, 44], two studies were conducted in the USA [36, 37], two in Spain [32, 33], one in Canada , one in the UK , one in Italy , and one in Finland . The types of studies comprised non-randomized clinical trials [30, 33], observational studies [31, 34, 36, 37, 39, 42,43,44], pilot intervention studies [29, 32, 38], and cost analysis [35, 40, 41]. Most studies used teledentistry consultations, either live or store and forward [29, 30, 32, 33, 35, 37, 40,41,42,43], and other studies used smartphone-based applications like WhatsApp [38, 44], the Oncogrid application for oral cancer surveillance , and videographic examination .
In several studies, teledentistry-based general dental examination and screening were done using intraoral cameras [29,30,31, 39, 42, 43]. In other studies, specialized dental services were provided such as oral and maxillofacial surgery for impacted third molar pathology, cleft lip and palate patient management, temporomandibular joint disorders [32, 33, 36, 37, 41], oral pathology for preventive screening of oral potentially malignant disorders , oral medicine and diagnosis for oral cancer surveillance [34, 38], and prosthodontics for dental prosthetics and oral rehabilitation . All of these specialized dental services primarily used the teledentistry model for specialist teleconsultations, disease screening, diagnosis and surveillance, treatment planning, preoperative assessment and management of patients requiring operative procedures, as well as referrals [31,32,33,34, 36,37,38, 41, 44].
Synthesis of the results
In three studies reporting patient satisfaction, 63 to 78% of patients were very satisfied with e-oral health care and 22 to 37% were satisfied [31,32,33]. Only one study reported dissatisfaction in one patient (0.3%) . All patients in these studies had shown willingness for teleconsultation for a dental problem [31,32,33]. As per Herce et al., 77.7% patients out of a total of 90 patients were very satisfied with this type of care, 22.3% patients were just satisfied, and no patient was unsatisfied . Similarly, Salazar-Fernandez et al.  reported that 63% of 283 patients were very satisfied, 36.7% were satisfied, and only 1 patient was unsatisfied. Patients were satisfied with such consultations due to saved travel time, saved working days, and prompt treatment onset . In addition, in the study by Ignatius et al. , 65% of 24 patients rated their satisfaction with the teleconsultation as 9 or 10 on a scale of 4 (worst) to 10 (best).
These studies reported association of patient satisfaction with travel time , prompt treatment initiation, and workdays not lost . As per Ignatius et al. , patient satisfaction was associated with the travel distance: the greater the distance of the patient's residence from the hospital, the greater the patient's satisfaction with e-oral health.
Moreover, Ignatius et al. reported that dental professionals were satisfied with the performance of teledentistry devices . Furthermore, in a study conducted by Wood et al. , general dental practitioners moderately agreed with benefits of teledentistry and expressed a desire to refer more patients through telemedicine consultations. While oral and maxillofacial surgeons were mostly neutral, they acknowledged that more referrals would influence their decision to provide telemedicine consultations and implement teledentistry in their practice .
Harmful effect of diagnostic errors made in e-oral health care interventions
There were no studies that found harmful effects, but five studies found that the e-oral health technology was reliable and in acceptable agreement with the standard consultations. According to Wood et al., 92.2% of the time, the practitioners were successful in making the diagnosis and treatment plan by using the teleconsultation data . Nearly 96% of the patients were given an accurate diagnosis and treatment plan, 99.6% of patients were triaged correctly, and 98.0% were given sufficient medical and physical assessment and immediately underwent surgery after teleconsultation .
Petruzzi et al., Patterson et al., Vinayagamoorthy et al., and Purohit BM et al. reported significant agreement between teledentistry consultation and clinicopathologic examination [29, 38, 39, 44]. According to Vinayagamoorthy et al., substantial agreement was found when the lesions were dichotomized as normal and abnormal (examiner 1 and 2, K reliability: 0.68 and 0.67, sensitivity: 98.5% and 99.04%, specificity: 72% and 64%), but slightly reduced when assessed for the exact diagnostic match (examiner 1 and 2, K reliability: 0.59 and 0.55, sensitivity: 98.1% and 98.7%, specificity: 64% and 52%) . Birur et al. reported 45% and 100% concordance with the specialists in the targeted cohort and opportunistic cohort respectively . In a study by Purohit BM et al., the sensitivity and specificity were 0.86 and 0.58 for videography-based teledentistry assessment .
Impact on waiting time, number of visits, travel, and the cost of care for patients
According to Herce et al. , the mean waiting interval for patients managed through teledentistry was 3.33 days since the visit to the primary care dentist compared to 28 days for those managed through the conventional referral system . The cancellation rate on-the-day of surgery for telemedicine was 7.8% and for the conventional system was 8.85% . Salazar-Fernandez et al.  found that both the teleconsultations and hospital visits were clinically effective . No statistically significant difference between the two techniques was noted for the rates of pathologies requiring assistance, patients requiring nonsurgical treatment, resolved consultations, and second teleconsultations . The effectiveness and efficiency also varied with the distance of the patient’s residence from the hospital [37, 41]. Teoh et al.  performed analysis of subgroups determined a priori, based on the distance travelled by the study participants (< 50 km, 50–80 km, 81–150 km, 151–225 km, and > 225 km). Based on the cost-effectiveness analysis, these authors concluded that the greater the distance between the patient's residence and the hospital, the more cost-effective and time-saving teledentistry intervention would be . For instance, the cost difference between tele- and hospital consultations at > 225 km distance was AU$ 458.85, the incremental cost-effectiveness ratio was − 10,550.45, the hours saved were 5.02, and the total distance saved was 450.03 km . Furthermore, this study showed that patients could save an average of 2 h and 21 min of travel time and 178.6 km of travel distance . However, this treatment modality was not as cost effective if a patient resided within 50 km of the hospital . As per the study by Wood et al. , average estimated distance of the patients from the clinic was 50 miles and the average roundtrip cost estimate of driving this distance was approximately $60.00 per patient.
As per Ignatius et al.  and Scuffman and Steed , the additional training of the general dental practitioners and familiarity with equipment and procedures were associated with better teledentistry related outcomes. Training may have higher initial cost but it can be cost-effective in the long run . Birur et al. also reported better concordance in the presence of trained onsite health workers such as in the diagnosis and surveillance of oral cancer .
Seven studies acknowledged teledentistry as a cost-effective and cost-saving method. A study by Estai et al.  compared traditional dental screening at school with teledentistry using a cost-minimization analysis. This study demonstrated the ability of teledentistry in minimizing the cost; for instance, the total estimated cost and fixed cost of the teledentistry model was $50 million and the estimated annual reduction with the teledentistry model was $85 million, which included staff salary savings, travel allowance avoided, and supply expenses avoided . Similarly, cost analysis by Marino et al.  showed that asynchronous teleconsultation was the lowest cost service model with AU$32.35 cost per resident compared to traditional face-to-face (average cost: AU$36.59 per resident) and real-time (average cost: AU$41.28 per resident) consultations.
According to Wood et al., consultation by telemedicine for 255 patients and eliminating in-office consultation saved a significant amount equivalent to $134,640 . In a model-based analysis, in Teoh et al.  the expected cost per consultation for conventional care was AU$431.29 and that for teledentistry was AU$294.35, saving an average AU$136.94 in societal costs per consultation. They also mentioned that teledentistry would save AU$50,258.92 in total costs per year, and that costs to the patient were reduced by 69% . Comparing the conventional care in hospital to teledentistry, the largest difference in cost savings was the costs to the patient including their transportation, accommodation, and lost productivity costs, amounting to AU$70,719.19 . The sensitivity analysis after adjustment of potential variables showed that teledentistry is a cost-saving option to society with the saving of $3,160.81 for every timely cleft lip and palate consultation compared to hospital consultation . Salazar-Fernandez et al.  reported the mean cost of lost working hours per patient was significantly less (50%) in teleconsultation (16.8 h) compared to the standard system (32.24 h).
Tynan et al. , on the other hand, compared three cost scenarios: screening by an oral health therapist in a residential aged care facility, teledentistry in a residential aged care facility, and resident attendance at an oral health clinic. Screening by an oral health therapist was deemed the lowest cost scenario when compared to the other two since the teledentistry setup in scenario 2 and dentist time in scenario 3 increased total costs . In a cost-minimization analysis by Scuffham and Steed , the cost of teledentistry was compared with two modes, outreach visits (specialist regularly visiting the two remote communities) and hospital visits. In both the communities, teleconsultation was associated with additional costs to the health organization and society compared with outreach visits . However, the cost savings for teleconsultation varied between the communities compared to hospital visits. In one community, cost savings were higher due to more travel time and travel cost . Nonetheless, the researchers concluded that teledentistry would be a cost-effective tool for the health organization in the long run .
Risk of bias assessment
Additional file 4 presents the risk of bias assessment tool in individual studies. Thirteen of the selected studies were found to have moderate risk of bias, and two other studies had critical risk in the overall assessment [29,30,31,32,33,34,35, 37,38,39,40,41,42,43,44]. One article was found to be ineligible for performing risk for bias assessment using the ROBINS-I tool . Table 2 shows the level of evidence according to the Oxford Centre for Evidence-Based Medicine . The majority of studies (11 out of 16) were considered level 4 and 3b.
Patients’ satisfaction with access to care in rural and remotes areas is one of the most important objectives of digital health. The findings of this systematic review suggest that 63% to 78% of patients living in rural and remote areas were very satisfied with e-oral health care interventions [31,32,33]. This satisfaction was mainly attributed to clinical effectiveness in making the diagnosis and treatment plan, less waiting time, prompt treatment onset, cost effectiveness, saved travel time, and saved working days [32, 33, 35, 37, 40,41,42,43]. Moreover, studies reporting on agreement of teledentistry consultation versus conventional dental consultations found comparable diagnostic reliability and validity values [32, 33, 35, 41].
Previous research has reported a rural–urban disparity regarding patients’ satisfaction with oral health care [46, 47]. Additionally, literature suggests that rural residents could have a higher level of satisfaction with oral health care services if they receive these services in a timely manner in their vicinity. For instance, a study on patient satisfaction with emergency oral health care services in rural Tanzania reported satisfaction among 92.7% of patients because of availability of these services in their area . Another study reported 80% satisfaction among patients visiting a rural dental institution in India .
The included studies also measured a wide range of other outcomes that were positively associated with e-oral health that we are not reporting here since they were not included in the published protocol. These outcomes include dental professionals’ satisfaction and perceptions about teledentistry [31, 36], perceived utility and demand for the application of telemedicine , surgery cancellation rate , number of appointments avoided at an oral health facility , and compliance with oral health care plan implementation .
The available emerging evidence and recent systematic reviews on e-oral health suggest that this technology is effective in promoting oral health and preventing dental problems, and that it has acceptable diagnostic performance [50,51,52]. Some authors have reported that tele-disease screening, tele-diagnosis, tele-consultations, treatment planning, and referrals, are comparable to face-to-face dentist-patient interaction [53, 54]. Additionally, according to previous studies these technologies seem to be beneficial in school-based programs, long-term care facilities, and areas with limited access to care, including rural and remote areas. However, in the absence of real comparative data it is hard to know how relevant these results are.
E-health services in rural and remote areas have been used for mental health, oncology, geriatrics, paediatric care, trauma treatment, specialist rheumatologist services, wound care management, and chronic disease management [55, 56]. Similar to our results, these e-health services were also found to be effective in rural areas in terms of better patient’s and professional’s satisfaction and acceptance, access to care, convenience, reliability, and reduced overall cost and travel time [55,56,57]. However, the success of e-health services in rural areas also depends on design and implementation of these services, information and technological support, as well as user training of the health personnel .
This systematic review reveals that multiple digital tools such as WhatsApp, emails, and videoconferencing have been used to connect oral health professionals and patients. This shows the necessity to work on formal teledentistry platforms. Furthermore, the type of digital tools will influence the quality of the diagnosis and the treatment plan. On the other hand, patients’ knowledge concerning the use of digital technologies is an important aspect and may influence patients’ expectation and satisfaction with the use of such technologies.
The satisfaction of patients may also be influenced by the type of dental care. For example, the use of teledentistry for early detection of oral cancer may result in higher patient satisfaction when compared with the tele-monitoring of the outcomes of orthodontic care. In fact, the use of digital technology should be encouraged in the prevention of oral diseases and improving access to care. According to the French national law on telemedicine enacted in 2009, the telemedicine activities should take into account “the deficiencies in the provision of care due to insularity and geographical isolation” . The WHO mOralHealth program  is an example of strategies that encourage worldwide e-oral health policies and programs to improve oral health literacy and access to care.
The recent development of e-health technologies and their integration and implementation in primary oral health care by interdisciplinary teams has the potential to address the dental needs of individuals in remote and rural communities, to provide satisfaction to these individuals, and to alleviate the burden of access to care. The findings also have the potential to empower the isolated dental workforce working in rural and remote zones across the world.
However, this review is limited due to its narrow inclusion criteria in regard to language and inclusion of various study designs, and caution should be taken when interpreting the results. Moreover, based on the level of evidence (Oxford Centre for EBM) and ROBINS-I assessments, most of the included studies had moderate or low quality as well as moderate to critical risk of bias. Furthermore, the reporting of outcomes in the included studies varies considerably. Although ROBINS-I is a comprehensive and rigorous tool for assessing bias risk, its reliability is questioned due to a lack of agreement among the examiners . These findings may affect the overall conclusions drawn in this study.
Our findings indicate significant inconsistencies in the methodologies of the included studies in terms of study setting, study design, sampling, data collection, and data analysis. Therefore, future high-quality studies using a mixed-method research design are required to provide quality data especially from end users’ perspectives. Quantitative data of the mixed methods should include randomized controlled trials with valid instruments allowing scoring patient satisfaction whereas the qualitative element can aid in gaining in-depth understanding of patients’ satisfaction with e-oral health. Standardized economic analyses are also required. Furthermore, future research on e-oral health should consider patient-centered oral health care, patient experiences with care, and the cost effectiveness of these technologies, particularly in underserved areas. Further research is needed to understand the role of e-oral health technologies in addressing rural oral health disparities. Moreover, research into the application of these technologies in academic settings will shed light on their significance in education.
Our results suggest that patient satisfaction could be associated with several modalities of e-oral health care. E-oral health seems a feasible option for providers who want to contribute to oral care services in rural and remote areas. However, only speculative conclusions can be drawn based on the quality of the included studies, implying that long-term robust cohort studies and clinical trials, as well as cost assessments on e-oral health in rural settings, are required in the future. As telehealth continues to be developed, special care should be given to incorporate features that further enable patients’ satisfaction and acceptance. On the other hand, as more patients are using telehealth, additional training for dentists is an important part of assuring better positive outcomes for patients.
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The authors thank M. Dupont, librarian at Université de Montréal, for his prompt collaboration in electronic search development and updating.
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Appendix 2. Search methodology.
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Emami, E., Harnagea, H., Shrivastava, R. et al. Patient satisfaction with e-oral health care in rural and remote settings: a systematic review. Syst Rev 11, 234 (2022). https://doi.org/10.1186/s13643-022-02103-2