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.

Table 1: Sociodemographic characteristics of participants (n = 43)

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).

Table 2: Participants’ attitudes regarding teledentistry (n = 46)

Attitudes, by category

No. (%) of participants

Note: SD = standard deviation.
aExcept where indicated otherwise.
bRespondents were asked to rank these 10 goals in order of importance. Data represent mean rankings across all respondents.

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]).

Table 3: Participants’ experience with using teledentistry

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) Email 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) WhatsApp 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 favoured (68% [30/44]), followed by simulation (61% [27/44]) and lectures (59% [26/44]). All options for key content of teledentistry training listed in the survey were perceived as useful by more than half of the respondents, with the applications (93% [41/44]), limitations (93% [41/44]) and benefits (89% [39/44]) of teledentistry being selected most often.

Table 4: Participants’ training needs in teledentistryVariable

Variable

No. (%) of participants

aMultiple responses allowed.

Awareness of guidelines/guidance on teledentistry in Canada (n = 44) Yes 1 (2) No 43 (98) Past formal education/training in teledentistry (n = 44) Yes 0 (0) No 44 (100) Ideal training format for learning teledentistry (n = 43) Incorporation of teledentistry in existing components of the curriculum 35 (81) New courses on teledentistry 8 (19) Best time in the dental program to receive teledentistry traininga (n = 44) Clinical dental education or clerkships 38 (86) Preclinical dental education 22 (50) I don’t know 1 (2) Ideal stage in the dental program to receive training in teledentistrya (n = 44) Fourth or fifth year 31 (70) Third year 21 (48) First or second year 18 (41) I don’t think that teledentistry should be taught at dental schools 4 (9) I don’t know 1 (2) Appropriate instructional methods for teledentistry traininga (n = 44) Hands-on experiences 30 (68) Simulation 27 (61) Lectures 26 (59) Online modules 24 (55) Case studies 22 (50) Small groups 19 (43) Group discussion 15 (34) Directed reading 7 (16) Writing reflection 7 (16) I don’t think that teledentistry should be taught at dental schools 4 (9) Key content for teledentistry traininga (n = 44) Applications of teledentistry 41 (93) Limitations of teledentistry 41 (93) Benefits of teledentistry 39 (89) Ethical issues related to teledentistry (e.g., malpractice, abuse, privacy) 37 (84) Equipment and software 37 (84) Virtual dental examination in a simulated environment or care of a real patient 36 (82) Modalities on delivery of care 36 (82) Teledentistry communication skills and building relationships 34 (77) Consent (verbal and written) 33 (75) Professionalism in teledentistry 33 (75) Cost-effectiveness of teledentistry 31 (70) Workflow related to teledentistry 31 (70) Data storage (e.g., methods, confidentiality, privacy) 30 (68) Troubleshooting technical issues 29 (66) Discussion

This study aimed to explore the attitudes, practices and needs of Canadian dental students regarding teledentistry. Dental students who responded to the survey had a positive attitude toward the usefulness of teledentistry in improving access to oral health care, ensuring continuity of care, addressing the shortage of oral health providers and facilitating communication among health care professionals. Based on their understanding of teledentistry, respondents identified the most common uses of this approach as screening, triage, follow-up and oral health promotion/education. This concordance between attitudes and experiences with teledentistry highlights the importance of individual factors in the adoption of health innovations. It also aligns with existing literature, which highlights access to care and tele-expertise as the most common advantages of teledentistry.14

These findings on teledentistry functions were also suggested and used during the COVID-19 pandemic to improve patients’ oral health outcomes.2,11 Respondents’ limited use of teledentistry for diagnosing and treating oral conditions and for prescribing medication may be explained by a lack of confidence or training and their reliance on supervisors for consultations. Interestingly, respondents did not emphasize the impacts of teledentistry on dental offices’ income or on reducing oral health care providers’ isolation, which highlights the importance of dental professionalism and the social contract in providing accessible oral health care.26,27

Although most respondents indicated that they had not used teledentistry, some reported having already engaged with both synchronous and asynchronous modalities of teledentistry. Phone calls were the most frequently reported modality, followed by text messaging and screen-sharing. This poor knowledge of teledentistry has been reported previously by oral health care providers and dental students. Authors of prior studies have highlighted their limited knowledge, practice and training about teledentistry.28-31 Given the limited guidance on teledentistry-related clinical practice available in Canada, the common use of phone calls may be attributed to lack of need for the internet, ease of use and higher likelihood that individuals will have a phone as opposed to other platforms, such as Zoom (Zoom Communications, San Jose, CA) or Microsoft Teams (Microsoft Corporation, Redmond, WA) , as well as a lack of organizational readiness to implement teledentistry. According to respondents, platforms such as WhatsApp (Meta, Menlo Park, CA), FaceTime (Apple, Cupertino, CA) and Skype gained attention for this purpose only during and after the COVID-19 pandemic. Email and text messages were reportedly the most common means of sharing documents with patients, likely due to their widespread familiarity.

In 2017, the American Student Dental Association recommended the incorporation of teledentistry into dental schools’ didactic curricula.32 However, despite the benefits of doing so, dental schools worldwide have been slow to integrate teledentistry into their curricula,16,17,19,33 which could explain the lack of awareness regarding guidance on teledentistry among respondents to our survey. Although the release of guidance on innovations such as teledentistry can increase dental students’ awareness of and knowledge about the topic, this passive implementation strategy has only a modest effect on behaviour change, including the adoption of evidence-based practices or policies.2

In alignment with prior research,10-14 most undergraduate dental students who responded to our survey had a positive attitude toward incorporating teledentistry training into the dental curriculum at any stage, with a notable preference for inclusion of this topic during the final years of study and clinical training. This finding highlights the relevance of this new modality of oral health care delivery for students’ future dental practice. Our results align with those from the medical field, where physician trainees highlighted the importance of digital health and telehealth education in their medical degrees and expressed interest in integrating telemedicine into their preclinical and clinical training.34,35 Educational training offers an opportunity to introduce students to telehealth innovations and to develop digital skills that enhance patient outcomes.32 Originally intended for clerkship students, the introduction of foundational concepts of virtual care in the educational journey34 or during the preclerkship phase36 has proven successful. This approach aims to enhance the development of knowledge and clinical reasoning, enabling students to compare virtual with in-person care, recognize appropriate usage and learn best practices.37,38

Interestingly, respondents to our survey indicated a preference for integrating teledentistry as part of an existing component of the curriculum rather than introducing it as a new course. This approach aligns with the relevance of adopting multifaceted educational interventions where telehealth training is combined with existing competencies such as exposure to rural care and interprofessional training.37 Among the educational content to be included in teledentistry training, respondents recommended comprehensive coverage of topics such as the applications, limitations, benefits and modalities of teledentistry, as well as ethical considerations, with a preference for hands-on experiences, as has been reported in the literature.19 Our findings for dental students contradict those of a study involving dental hygienists, who showed a greater inclination toward didactic lectures, preclinical and clinical practices, and simulated cases.14 More than half of the dental hygiene student participants in that prior study expressed the relevance of integrating teledentistry training into dental hygiene extramural community rotations.14 While various approaches exist to address the need for increased exposure to teledentistry in undergraduate education, their dynamism underscores the importance of delivering comprehensive knowledge and skills to future health care providers.38 Considering the unprecedented development of innovation, moving beyond the simple exposure of students to telehealth technology is essential to equip them through evidence-informed digital clinical practice.37

To the best of our knowledge, this study is the first to investigate the perspectives of undergraduate dental students regarding the integration of teledentistry in Canadian dental schools. The insights from this study provide valuable information for decision-makers aiming to integrate teledentistry into dental curricula. Additionally, the findings guide attention toward specific programmatic stages where the inclusion of teledentistry topics would be most beneficial, influencing content and procedural considerations. However, this study was limited to dental students in 3 Canadian provinces and had a low participation rate, which restricts the generalizability, external validity and applicability of our findings to all Canadian dental schools. A key disadvantage of online surveys is their typically lower response rates (relative to other survey methods). In addition, the complete case analysis approach that we chose to handle missing data reduced the sample size of the population and may have introduced nonresponse bias.39 We recognize that nonrespondents may have lacked interest in teledentistry, potentially affecting the representativeness of our sample. The target population was students in the third year and above, but students at the preclinical stage (first and second years) might have different perspectives. Therefore, caution must be exercised in interpreting the results. Future research should encompass a broader range of dental schools and should solicit participation from all undergraduate students to enhance the extent and validity of study results. Additionally, further studies should explore oral health care providers’ perspectives about teledentistry implementation to better understand their anticipated and perceived barriers and enablers, as well as strategies to optimize its successful adoption.

Conclusion

The findings from this study shed light on important variables to consider when promoting teledentistry training and education within dental curricula. Dental students responding to our survey expressed a lack of knowledge about teledentistry use, coupled with positive attitudes and limited experience, all of which highlight the need to integrate teledentistry into undergraduate training. As such, dental schools can play a crucial role in preparing the next generation of oral health care providers for the optimal use of teledentistry. Integration of this modality into dental curricula presents an opportunity for students to develop essential teledentistry skills and competencies, ultimately influencing their performance to enhance the overall quality of care and patients’ outcomes.

THE AUTHORS

 

Dr. Kengne Talla is assistant professor, faculty of dental medicine and oral health sciences, McGill University, Montreal, Quebec.

Dr. Michaud is full professor and head of the division of prosthodontics, department of dental clinical sciences, faculty of dentistry, Dalhousie University, Halifax, Nova Scotia.

Dr. Durand is full professor, department of oral health, faculty of dentistry, University of Montreal, Montreal, Quebec.

Dr. Emami is full professor and dean, faculty of dental medicine and oral health sciences, McGill University, Montreal, Quebec.

Corresponding author: Dr. Pascaline Kengne Talla, Dental Medicine and Oral Health Sciences, McGill University, 2001, avenue McGill College, Montreal, QC H3A 1G1. Email: pascaline.kengnetalla@mcgill.ca

The authors have no declared financial interests.

This article has been peer reviewed.

Acknowledgements
The principal investigator, Dr. Kengne Talla, received start-up funding from the faculty of dental medicine and oral health sciences at McGill University. The authors thank Dr. Lavekar Ajinkya, a non-thesis master’s student, for his contribution to survey development using Lime Survey. The authors would also like to recognize the support of biostatistician Pierre Rompré. Additionally, they would like to thank summer students Bushra Khan and Annie Wiseman for their involvement in the initial phases of this project. Finally, the authors are grateful to the undergraduate dental students who participated in this project by responding to the survey.

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