Telediagnosis of Oral Disease- A Research Report

Jair Carneiro LEÃO^1,2
Stephen R. PORTER¹

¹Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University of London, London, England
²Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Recife, PE, Brasil

Computers have increasingly found application in dentistry over the past 15 years, but at present there has been no investigation of the application of the Internet for distance diagnosis purposes in oral medicine. As a consequence, the objective of this article was to determine the acceptability to patient and clinician of the distant diagnosis of common orofacial diseases using the Internet. The study group comprised 20 patients who attended the Oral Medicine unit of the Eastman Dental Institute and Hospital, London, UK, for the diagnosis and management of oral mucosal diseases. Digital images of each patient's oral mucosal lesion were captured and stored on a personal computer and later transmitted via the Internet to a distant site. Patients were asked to complete a self-administered questionnaire detailing their opinion of the use of an intra-oral camera and a group of clinicians were asked to compare and contrast the original and transmitted images. The majority of patients found the procedure of recording images of their mouth very comfortable, were happy to view the inside of their mouths, and found the procedure generally useful in understanding their clinical problem. The clinicians were often not able to differentiate between the original and transmitted image but were able to accurately diagnose the patients oral mucosal problems in 64% of the instances. The results of the present study suggest that telediagnosis of orofacial disease may be a feasible prospect.

Introduction
    Computer technology has increasingly found application in clinical dentistry, particularly as computer hardware becomes cheaper, more widely available and more effective. In 1991, only about a quarter of all UK dental practices had appropriate computers (Eaton, 1994); however, the number of dental practices using computers is likely to increase significantly following the introduction of electronic data transmission of treatment schedules (Hammond et al., 1993). In addition, the rapid acceptance of the Internet and the World Wide Web as means of communication (Sund and Rinde, 1995) suggests that increasing numbers of medical and dental clinicians will use computers for many applications in clinical practice.
    To date computers have principally been employed in clinical dentistry for tasks such as recording patient appointments (Zimmerman et al., 1986), treatment schedules (Hammond et al., 1993) and other administrative duties (Abbey, 1987; Lee et al., 1995). There is, however, a great need to develop appropriate methods for distance diagnosis using computer technology.
    Telemedicine (telecommunication-supported medicine) permits doctors to investigate and treat patients via videoconferencing and electronic information exchange. Instead of patients being transported to the site of a clinician (or vice versa), digitized patient information is transmitted to the clinician thus saving time, transport and money.
    Use of telemedicine systems has varied between medical specialties. Radiology is probably the main user of telemedicine technology: digitized radiological images can be electronically distributed to distant clinical settings, for example Saudi Arabia to the USA (Goldberg et al., 1994).
    In addition, studies have also been undertaken in psychiatry (Kavanagh and Yellowlees, 1995; Baer et al., 1995), pathology (Nagase, 1995; Eusebi et al., 1997), rheumatology (Pal, 1997), orthopedics (Delaplain et al., 1993), dermatology (Norton et al., 1997; Perednia, 1997; Kvedar et al., 1997), otorhinolaryngology (Crump and Driscoll, 1996), oncology (Kunkler et al., 1997) and HIV medicine (Frank et al., 1997).
    In the UK, medical clinicians have assessed the possible benefits of communication between primary and secondary health care providers using ISDN (Integrated Systems Digital Network)-based technology. The ISDN-2 system employed in most of these evaluations permits digitized data to be transmitted rapidly at a bandwidth of 128 kilobytes per second and thus allows still and moving color images to be transmitted in real time, without visual degradation with distance.
    Evaluation of ISDN-2 technology in the practices of dermatology, histopathology and psychiatry suggest that such off-the-shelf technology may be of some clinical benefit in the diagnosis of disease by specialist health care workers at sites distant from the patient and primary health care worker (Malone et al., 1997). The ISDN-2 system does not provide appropriate bandwidth for real-time transmission of moving images, but this can be overcome by the use of additional ISDN lines.
    Although ISDN technology is readily available worldwide, the necessary hardware is still expensive in relation to the cost of a personal computer (PC). In contrast, the hardware and software required for the use of the Internet is inexpensive and all countries have ready access to it. The aim of this study was thus to determine the possible acceptability of recording and transmitting clinical images of patients with orofacial diseases via the Internet, and thus develop the application of the use of this network in the distant diagnosis of oral disease.


Discussion
    Computers have had many applications in clinical dentistry, but to date their possible use in teledentistry has not been fully investigated. The ability for clinicians to communicate quickly and effectively is important to ensure appropriate patient management (e.g., the early diagnosis of oral malignancy), and subsequent education of the primary health care staff. To date the distant diagnosis by electronic means has principally been employed in medical specialities such as radiology, dermatology pathology and psychiatry; there is little data on the practical aspects and benefits of this to dentistry.
    The present study is the first to investigate the practical aspects of teledentistry, i.e. acceptability to patients and the ability of clinicians to provide provisional diagnosis of orofacial disease when provided with images and clinical details transmitted from a distant site via the Internet.
    In the present study only one of the twenty study patients had previously had images of their orofacial tissues captured electronically, nevertheless after appropriate explanation by the attending clinician the majority of patients believed that they understood why they were having the procedure and generally did not find it to be time consuming or uncomfortable. Only 12 (60%) of the patients regarded their viewing of the images of their orofacial disease as acceptable, but 13 (65%) did believe that it provided a fuller understanding of their orofacial problem. All images were transmitted during working hours as attached files, thus there was a delay of up to 30 minutes in the images arriving at the second PC. There was, however, no notable degradation of the images as a result of transmission, as both clinical and non-clinical judges could not reliably distinguish between the original and transmitted images.
    The clinicians could generally make a differential diagnosis based upon the electronic data transmitted. Indeed, despite the clinical judges being relatively junior clinicians, they provided the appropriate provisional diagnosis in 64% of instances. It is thus evident that if this method of communication was to be employed in regular clinical use, it is likely to be of practical benefit, permitting secondary health care staff with appropriate information to give primary health care staff the appropriate advice. The personal computers and videocapture card used in this study were, deliberately, not especially complex or expensive models, and thus likely to be within the financial constraints of general dental practitioners likely to have intra-oral digital cameras. Thus as the cost of such equipment continues to fall, the potential for distant diagnosis of orofacial disease will increase.
    Despite the aforementioned data suggesting that the digital recording of images of orofacial disease and the transmission via the Internet is a practical and effective means of communication, not all images were adequately interpreted by clinicians. In addition, although the clinical images and patients details were transmitted separately there is a need for some method of encryption to ensure the data cannot be read by non-involved parties, if data is inadvertently transmitted to the wrong site. The clinical judges did not view the transmitted images at the time of their transmission (i.e., interpretation was not in real-time). Information sent via the Internet generally does not pass directly from the sender to the recipient, instead as found in this study it can take considerable time before the message reaches the recipient, thus this means of transmission of clinical data may be inappropriate when a clinical opinion, based upon transmitted data, is required urgently.
    In conclusion the results of the present study suggest that teledentistry using the Internet may be a practical means of communication between dental clinicians and hence improve the management of patients with orofacial disease. There is, however, a need to undertake a more detailed study of a wider variety of orofacial diseases and compare the efficacy of transmission of clinical data via the Internet with other technologies, such as ISDN, that permits rapid transmission of a large amount of data, hence, real-time diagnosis of disease.

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