A resource reallocation model for school dental screening: taking advantage of teledentistry in low-risk areas.

OBJECTIVE: To estimate the scale of resource transfer that could be achieved by screening low-risk schoolchildren using teledentistry rather than using traditional visual dental examination. METHODS: This study was based on a previous cost-minimisation study that compared the costs of two dental-screening approaches (visual and teledentistry). The data for the population of children 5-14 years of age was obtained from the Australian Bureau of Statistics and was divided across Australia according to statistical local area (SA2). The cost models (for teledentistry and visual screening) for each SA2 relative to the state, Remoteness Area (RA) and Socio-Economic Index for Area (SEIFA) indexes were estimated. The geographical information system was used to superimpose modelled cost data on the geographical map to provide a visual presentation of the data. Resource transfer scenarios, based on risk minimisation, were then developed and analysed. RESULTS: This study demonstrated a suboptimal allocation of dental-care resources, such that children living in high socio-economic areas (major cities) with low disease burdens consuming half of the estimated resources of a universal visual dental screening system. The findings suggest that utilising teledentistry screening for low-risk children has the potential to free up $40 million per annum. Such resources can be reallocated to increase care access and improve the quality of dental services for vulnerable children. CONCLUSION: To reduce inequalities in dental health within a community, scarce health-care resources should be targeted at the population at most risk. These findings can be used to inform policymakers, guide the appropriate distribution of scarce resources and target dental services to benefit high-need children.

A systematic review of the research evidence for the benefits of teledentistry.

Objective This review is designed to inform future decisions about the benefits of integrating teledentistry into routine health services, by presenting an overview of the evidence for the effectiveness and economic impact of teledentistry. Methods Two reviewers searched PubMed, EMBASE and CINAHL databases through November 2016 to identify published peer-reviewed studies in English. Teledentistry studies were included if they were; (a) controlled (randomised or non-randomised) assessment studies; and (b) compared outcomes of a teledentistry intervention in terms of clinical or economic evaluation with the outcomes of traditional clinical alternatives. The quality of the studies was evaluated using a quality appraisal tool that considered study performance and design. Results This review identified 385 publications, of which 217 full-text articles were retrieved for further inspection. Of these, only 11 articles met the inclusion criteria. Nine of the included articles showed some clinical outcomes; the other two were primarily economic analyses. The balance of these studies assesed the efficacy of teledentistry interventions rather than their effectiveness. Four studies (36%) achieved higher quality scores and have greater potential to influence health-care decision-making. To date, the most convincing published evidence regarding the efficacy of teledentistry was provided by studies on paediatric dentistry, orthodontics and oral medicine. The economic analysis referred only to cost-minimisation, suggesting that the use of teleconsultation in dentistry can be cost-saving when compared to a conventional consultation. However, high-quality economic studies on teledentistry are rare. Conclusion There is emerging evidence supporting the efficacy of teledentistry. However, there is not yet enough conclusive evidence, particularly for its effectiveness, cost-effectiveness and long-term use, to make evidence-based policy decisions on teledentistry.

Cost savings from a teledentistry model for school dental screening: an Australian health system perspective.

Objective The aim of the present study was to compare the costs of teledentistry and traditional dental screening approaches in Australian school children. Methods A cost-minimisation analysis was performed from the perspective of the oral health system, comparing the cost of dental screening in school children using a traditional visual examination approach with the cost of mid-level dental practitioners (MLDPs), such as dental therapists, screening the same cohort of children remotely using teledentistry. A model was developed to simulate the costs (over a 12-month period) of the two models of dental screening for all school children (2.7million children) aged 5-14 years across all Australian states and territories. The fixed costs and the variable costs, including staff salary, travel and accommodation costs, and cost of supply were calculated. All costs are given in Australian dollars. Results The total estimated cost of the teledentistry model was $50million. The fixed cost of teledentistry was $1million and that of staff salaries (tele-assistants, charters and their supervisors, as well as information technology support was estimated to be $49million. The estimated staff salary saved with the teledentistry model was $56million, and the estimated travel allowance and supply expenses avoided were $16million and $14million respectively; an annual reduction of $85million in total. Conclusions The present study shows that the teledentistry model of dental screening can minimise costs. The estimated savings were due primarily to the low salaries of dental therapists and the avoidance of travel and accommodation costs. Such savings could be redistributed to improve infrastructure and oral health services in rural or other underserved areas. What is known about the topic? Caries is a preventable disease, which, if it remains untreated, can cause significant morbidity requiring costly treatment. Regular dental screening and oral health education have the great potential to improve oral health and save significant resources. The use of role substitution, such as using MLDPs to provide oral care has been well acknowledged worldwide because of their ability to provide safe and effective care. The teledentistry approach for dental screening offers a comparable diagnostic performance to the traditional visual approach. What does this paper add? The results of the present study suggest that teledentistry is a practical and economically viable approach for mass dental screening not only for isolated communities, but also for underserved urban communities. The costs of the teledentistry model were substantially lower than the costs associated with a conventional, face-to-face approach to dental screening in both remote and urban areas. The primary driver of net savings is the low salary of MLDPs and avoidance of travel and overnight accommodation by MLDPs. What are the implications for practitioners? The use of lower-cost MLDPs and a teledentistry model for dental screening has the potential to save significant economic and human resources that can be redirected to improve infrastructure and oral care services in underserved regions. In the absence of evidence of the economic usefulness of teledentistry, studies such as the present one can increase the acceptance of this technology among dental care providers and guide future decisions on whether or not to implement teledentistry services.

End-user acceptance of a cloud-based teledentistry system and Android phone app for remote screening for oral diseases.

Objective This study aimed to evaluate users' acceptance of a teledentistry model utilizing a smartphone camera used for dental caries screening and to identify a number of areas for improvement of the system. Methods A store-and-forward telemedicine platform "Remote-I" was developed to assist in the screening of oral diseases using an image acquisition Android app operated by 17 teledental assistants. A total of 485 images (five images per case) were directly transmitted from the Android app to the server. A panel of five dental practitioners (graders) assessed the images and reported their diagnosis. A user acceptance survey was sent to the graders and smartphone users following completion of the screening program. Results Of the 22 surveys sent out, 20 (91%) were completed. Generally, users showed optimism towards the use of the teledentistry system, and strongly positively assessed items on content and service quality. The majority of graders took less than 15 min to read the images while phone users took 5-10 min to complete the dental photography using the Android app. This study identified a number of factors that are essential for improving the current system, such as optimization of smartphone camera features, the format of the server, and the orientation of images and using oral retractors during photography. Conclusions Users appear to be generally satisfied with the proposed teledentistry model. However, they have specific concerns to address, many of which could be resolved through more effective training, coordination between sites and upgrading the current system.

Comparison of a Smartphone-Based Photographic Method with Face-to-Face Caries Assessment: A Mobile Teledentistry Model.

OBJECTIVES: This study sought to evaluate the efficacy of a mobile teledentistry approach using a smartphone camera for remote screening of dental caries. MATERIALS AND METHODS: An image acquisition Android App was created to facilitate the acquisition and transmission of dental images to a store-and-forward based telemedicine server. One hundred participants who were attending routine checkups at dental clinics were enrolled in 2014. Following a face-to-face oral screening by a screener (dentist), images of patients' teeth were obtained using a smartphone camera. These images, along with patient information, were then transmitted from the Android App to the server through the Internet for later independent assessment by two charters (off-site dentists). The assessments of these charters were then compared to the benchmark face-to-face caries assessment. RESULTS: Sensitivity values for the photographic method when compared to the benchmark face-to-face caries assessment were moderate, and ranged from 60% to 63%. Weighted kappa (K) as a measure of intragrader agreement for the photographic assessment was estimated as almost perfect (K = 0.84). The intergrader agreement for the photographic method compared to the face-to-face caries assessment ranged from moderate to substantial (K = 0.54-0.66). CONCLUSIONS: Despite some limitations, the mobile teledentistry approach has shown the potential to detect occlusal caries from photographs taken by a smartphone camera with an acceptable diagnostic performance compared to traditional face-to-face screening. This study suggests that telemedicine and cellular phone technology can be combined to create an inexpensive and reliable screening tool.

Challenges in the uptake of telemedicine in dentistry.

With the availability of oral care services very unevenly distributed in rural or remote areas, underserved people seek oral care from non-dental care providers. Against this backdrop, and coupled with the decreasing cost of and innovations in technology, there is a growing interest in the adoption of telemedicine services. Regardless of the lack of good-quality evidence supporting the cost-effectiveness of telemedicine, evidence already indicates that telemedicine, even with extra costs, helps in reducing the inequalities in the provision of primary health care. Telemedicine has the potential to overcome geographical barriers and contribute to closing the rural-urban healthcare gap in Australia and many other regions. Although research examining different teledentistry applications has found that this technology can be successfully integrated into different settings, there is little active teledentistry practice in Australia. The integration of telemedicine into the mainstream oral health system is a complex and collaborative process in which numerous factors at individual, infrastructure and organisational levels are involved. Addressing the barriers that delay the implementation of a teledentistry service can provide valuable insights into its lack of acceptance and establish an evidence base that can help to inform future decisions about the benefits of teledentistry.

Diagnostic accuracy of teledentistry in the detection of dental caries: a systematic review.

OBJECTIVE: This study sought to systematically review the literature for research evidence for the diagnostic accuracy of teledentistry in the detection of dental caries. METHODS: Two reviewers searched PubMed, EMBASE, and Scopus databases through January 2016 for comparative studies that examined the diagnostic accuracy of teledentistry for detecting caries compared with nontelemedicine alternatives. Retrieved studies were screened for inclusion criteria and were evaluated for methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) checklist. RESULTS: Of 287 citations identified, 10 met the preset inclusion criteria. Sensitivity and specificity were the most common measures of diagnostic accuracy used in 10 studies. Despite very limited published evidence on the diagnostic accuracy of teledentistry, the reviewed teledentistry studies showed comparable diagnostic performance compared with nontelemedicine alternatives. The average methodological quality of the selected articles is low, since none of the selected studies satisfied all 4 QUADAS-2 domains. Only 6 articles were scored as having a low risk of bias in 3 of 4 of QUADAS-2 domains. All the selected studies had low concerns regarding applicability. The main shortcoming was that in most of the selected studies, the methodology, in particular patient selection and index tests, was insufficiently described. CONCLUSIONS: Teledentistry has an acceptable diagnostic performance in the detection of dental caries. However, due to the heterogeneity of the reviewed studies, the generalization of results may be difficult. Further well-designed research to investigate the effectiveness of the teledentistry approach to caries detection is needed to determine the capability of this technology in epidemiologic oral surveys.

Best teaching practices in anatomy education: A critical review.

In this report we review the range of teaching resources and strategies used in anatomy education with the aim of coming up with suggestions about the best teaching practices in this area. There is much debate about suitable methods of delivering anatomical knowledge. Competent clinicians, particularly surgeons, need a deep understanding of anatomy for safe clinical procedures. However, because students have had very limited exposure to anatomy during clinical training, there is a concern that medical students are ill-prepared in anatomy when entering clerkships and residency programs. Therefore, developing effective modalities for teaching anatomy is essential to safe medical practice. Cadaver-based instruction has survived as the main instructional tool for hundreds of years, however, there are differing views on whether full cadaver dissection is still appropriate for a modern undergraduate training. The limitations on curricular time, trained anatomy faculty and resources for gross anatomy courses in integrated or/and system-based curricula, have led many medical schools to abandon costly and time-consuming dissection-based instruction in favour of alternative methods of instruction including prosection, medical imaging, living anatomy and multimedia resources. To date, no single teaching tool has been found to meet curriculum requirements. The best way to teach modern anatomy is by combining multiple pedagogical resources to complement one another, students appear to learn more effectively when multimodal and system-based approaches are integrated. Our review suggests that certain professions would have more benefit from certain educational methods or strategies than others. Full body dissection would be best reserved for medical students, especially those with surgical career intentions, while teaching based on prosections and plastination is more suitable for dental, pharmacy and allied health science students. There is a need to direct future research towards evaluation of the suitability of the new teaching methodologies in new curricula and student perceptions of integrated and multimodal teaching paradigms, and the ability of these to satisfy learning outcomes.

More accurate neuronavigation data provided by biomechanical modeling instead of rigid registration.

It is possible to improve neuronavigation during image-guided surgery by warping the high-quality preoperative brain images so that they correspond with the current intraoperative configuration of the brain. In this paper, the accuracy of registration results obtained using comprehensive biomechanical models is compared with the accuracy of rigid registration, the technology currently available to patients. This comparison allows investigation into whether biomechanical modeling provides good-quality image data for neuronavigation for a larger proportion of patients than rigid registration. Preoperative images for 33 neurosurgery cases were warped onto their respective intraoperative configurations using both the biomechanics-based method and rigid registration. The Hausdorff distance-based evaluation process, which measures the difference between images, was used to quantify the performance of both registration methods. A statistical test for difference in proportions was conducted to evaluate the null hypothesis that the proportion of patients for whom improved neuronavigation can be achieved is the same for rigid and biomechanics-based registration. The null hypothesis was confidently rejected (p < 10(-4)). Even the modified hypothesis that fewer than 25% of patients would benefit from the use of biomechanics-based registration was rejected at a significance level of 5% (p = 0.02). The biomechanics-based method proved particularly effective in cases demonstrating large craniotomy-induced brain deformations. The outcome of this analysis suggests that nonlinear biomechanics-based methods are beneficial to a large proportion of patients and can be considered for use in the operating theater as a possible means of improving neuronavigation and surgical outcomes.

Mechanical properties of the brain-skull interface.

Knowledge of the mechanical properties of the brain-skull interface is important for surgery simulation and injury biomechanics. These properties are known only to a limited extent. In this study we conducted in situ indentation of the sheep brain, and proposed to derive the macroscopic mechanical properties of the brain-skull interface from the results of these experiments. To the best of our knowledge, this is the first ever analysis of this kind. When conducting in situ indentation of the brain, the reaction force on the indentor was measured. After the indentation, a cylindrical sample of the brain tissue was extracted and subjected to uniaxial compression test. A model of the brain indentation experiment was built in the Finite Element (FE) solver ABAQUS™. In the model, the mechanical properties of the brain tissue were assigned as obtained from the uniaxial compression test and the brain-skull interface was modeled as linear springs. The interface stiffness (defined as sum of stiffnesses of the springs divided by the interface area) was varied to obtain good agreement between the calculated and experimentally measured indentor force-displacement relationship. Such agreement was found to occur for the brain-skull interface stiffness of 11.45 Nmm⁻¹/mm². This allowed identification of the overall mechanical properties of the brain-skull interface.

Local retention of soluble antigen by potential antigen-presenting cells in the anterior segment of the eye.

PURPOSE: To determine the capacity of bone marrow-derived cells in the anterior segment of the eye to capture a fluorescence-labeled antigen (Ag) injected into the anterior chamber (AC). METHODS: Uveal tract and corneoscleral tissues from Lewis rats were cultured in vitro, with or without FITC-dextran (4 microg/mL final concentration), for 48 hours and examined by confocal microscopy. To investigate antigen uptake in vivo 2 microL (20 microg) of Cascade Blue-labeled dextran (CB-Dx) was injected into the right AC of Lewis rats. The density of Ag-positive cells in the iris at 1, 3, 5, or 12 days after injection was examined by in vivo video fluorescence microscopy. The distribution and phenotype of Ag-positive cells in frozen and paraffin-embedded sections of ocular tissues and in iris wholemounts from animals killed at 24 hours and day 7 were analyzed by fluorescence and confocal microscopy. RESULTS: In organ culture conditions numerous cells in the iris, ciliary body, choroid, and corneal limbus were capable of capturing fluorescence-labeled Ag. In vivo observations and microscopic examination of experimental eyes at days 1 and 7 after AC injection revealed Ag-positive cells within the iris, iridocorneal angle, the suprachoroidal space and around limbal-episcleral vessels. Ag-bearing cells in the iris express combinations of macrophage markers but rarely expressed major histocompatibility complex (MHC) class II molecules. A reduced number of Ag-bearing cells were still present in the iris at day 12. CONCLUSIONS: Potential antigen-presenting cells (APCs) in the iris and ciliary body are capable of internalizing intracameral Ag. The characteristics of these cells in the iris are consistent with a predominantly macrophage phenotype. These observations also suggest that the Ag leaving the eye through both the conventional and nonconventional aqueous outflow pathways may be captured by potential APCs in the episcleral tissues.

Macrophage recognition and phagocytosis of apoptotic fibroblasts is critically dependent on fibroblast-derived thrombospondin 1 and CD36.

The induction of fibroblast apoptosis and their clearance by phagocytes is essential for normal wound healing and prevention of scarring. However, little is known about the clearance of apoptotic fibroblasts and whether apoptotic cells are active participants in the recruitment and activation of phagocytes. In this study, we provide the first evidence that apoptotic fibroblasts actively release increased amounts of thrombospondin (TSP1) to actively recruit macrophages. Expression of TSP1 and its receptor CD36 was increased on the surface of apoptotic fibroblasts. By chemical cross-linking and immunoprecipitation we show that TSP1 and CD36 were directly associated. This was confirmed by confocal microscopy. Blockade of either CD36 or TSP1 on apoptotic fibroblasts inhibited phagocytosis. Blockade of alpha v beta 3 integrins as well as CD36 and TSP1 on macrophages inhibited phagocytosis. In contrast, phosphatidylserine or lectins were not involved. These findings suggest that apoptotic fibroblasts release TSP1 as a signal to recruit macrophages while the up-regulated expression of the CD36/TSP1 complex on their cell surface may form a ligand bridging the fibroblast to a complex consisting of alpha v beta 3/CD36/TSP1 on macrophages. These results establish fundamental mechanisms for the clearance of apoptotic fibroblasts and may provide insights into the processes involved in normal wound repair.