Dentists’ Self-perception on Teledentistry: The Changing Landscape Driven by Technological Booming in the 21Century

This cross-sectional study was conducted between January and December 2017 and recruited a convenience sample of dental practitioners, whose self-perceptions of the practice-related use of teledentistry were assessed viaateledentistry survey (TDS). The TDS consisted off our sections:efficiency in patient care, cost reduction,capabilities forimproving practice, and security and confidentiality.Data analyseswere conducted throughdescriptive statistics,internalreliability tests(Cronbach’s alpha), andchi-squaredtests of the TDS.


INTRODUCTION
In healthcare, the fields of Information Technology (IT) and telecommunication are continuously evolving. Terms,like "telemedicine,""teledentistry,"and "telepharmacy" have emerged in recent decades [1]. The word"teledentistry" was first introduced inthe year1997 by Cook, who defined it as "the practice of using videoconferencing technologies to diagnose and provide advice about treatment over distance" [2,3].
Teledentistryis being used with increasing frequency around the world -particularly in North America, Australia, South Africa, and the Scandinavian countries [4 -7]. In addition, a growing body of literature has investigated theideaand efficacy of teledentistry. For instance, a qualitative andsystematic reviewof 39 studies,which reported attitudes toward teledentistry and the implementation of teledentistry in practice, concluded that "there isa high acceptability for teledentistry amongst clinicians and patients alike" [8]. Teledentistry is also considered a practical and potentially costeffective method,overcoming geographical time barriers, and increasing access to healthcare services. It has great potential foraddressing challenges at both the patient and providerlevels, especially when dental expertise is urgently required [9].
In some contexts, gender is a significant determinant of intentions to accept new technology, but there are cases in which gender differences cannot be discerned. For example, men are found to be more technologically adeptthan women in the context of IT use computers, email, web services, electronic data management systems,etc. In contrast, the gender difference is not observed with interactionson social media platforms, but males and females do have different agendasfor using social networking sites. Females mainly use social media to maintain existing relationships, whereas males use it to make new friends [10].
Exploring gender differences in the adoption of teledentistry can identify techniques through which the gender gap in teledentistry acceptance if present can be addressed. Dental institutions, both private and public, can accordingly design specific programs aimed to understand the gender difference and enhance the skills of practitioners, who are more apprehensive about using emerging dental technological applications.
However, in the Saudi Arabian context, limited evidence is available on dentists'viewsof adoptingtele dentistry and onthe gender differences affecting technology adoption between male and female general practitioners.Thus, this study assessed dental practitioners' self-perceptions of teledentistry and searched for possible gender-related differences in Saudi Arabia.Sinceinformation and communication technology has been implemented in almost all modern daily tasks, including dental care delivery, the authors hypothesized that teledentistry would be generally well perceived by dentists in Saudi Arabia and that gender would have no role in this context.

Study Design and Sampling
This cross-sectional study was conducted between January and December 2017, and the participants were recruited byconvenience sampling. The research survey was distributed using social network sites, such as Twitter, Facebook, LinkedIn, WhatsApp, etc. The researchers' affiliation networks with their fellow dentists were also used as a strategy to recruit participants from different Saudi regions.

Measures and Data Collection
The sample size was calculated using Epi Info StatCalc, considering the population size of 16,887 licensed dentists [11] and a 99% confidence level, with expected frequencyof50%. The sample was 164 participants from registered general dental practitioners and dental specialists working in Saudi Arabia with an acceptable power of 80%.A total of 800 anonymous, electronic, self-administered questionnaires were sent to participants using a direct link to a Google form. Upon completion of the survey, respondents were instructed to submit the web form. The web server entered the data into an Excel database created to store and retrieve data for analysis.
The structured questionnaire was written in English and included two sections. The first was composed of eight questions relating toparticipants' sociodemographic characteristics (i.e., age, gender, and nationality) and qualifications (i.e., years of work experience in dentistry, location of themain job, theaverage number of hours/day spent on the internet for work-related matters and general use, and most common way of communicating with colleagues). The second section included the TDS, which comprised foursubsections. Subsection 1 contained seven questions on theusefulness of teledentistry. Subsection 2 posed five questions on teledentistry efficiency. Subsection3 presented sevenquestions onthe benefits of teledentistry, and Subsection 4 included four questions on the practice-related use of teledentistry. Responses were rated on a five-point Likert scale (1= strongly disagree,and 5 = strongly agree) [12].

Statistical Analysis
For analysis, the Excel database was exported into IBM SPSS software (ver.24.0; IBM, Chicago, IL, USA).Descriptive statistics (frequency, percentage, andmean± standard deviation) were gatheredto determine respondents' characteristicsand dentists'perceptions and concerns in the teledentistry use. The internal consistency (Cronbach's alpha) of the TDS was also assessed. These analyses were conducted both for the entire sample and for each gender. Chi-squared tests were similarly used to examine the interaction between genders in the TDS item responses. The TDS responses were then collated into 'Agree and Strongly Agree, 'Neutral,' and 'Disagree and Strongly Disagree' to ease interpretation. The statistical significance tests (p-values) were set to p<0.05.

Sociodemographic Characteristics of the Sample
Out of the 800survey questionnaires disseminated, 620 useful and completed surveys were analyzed.Surveys of dentists who were not licensed to practice dentistry in Saudi Arabia, dental practitioners not working in Saudi Arabia, and surveys with missing datawere excluded. The internal reliability of the TDS was 0.85 for the whole sample and 0.85 and 0.90 for males and females, respectively.

Internet Usage and Preferred Medium of Communication
As shown in Table 2, 406 (66%) participants spent more than five hours per day using the internet for general purposesunrelated to dentistry, and 453 (73%) used the internet for less than four hours per day for work-related issues. The participants reported their preferred methods of communicating with colleagues to be either email (64%) or phone (64.4%). Videoconferencing (9.2%) and forums (5.2) were aless preferable medium of communication among practitioners.

Efficiency in Patient Care
75%of the sample agreed that teledentistry could be useful forimprovinginteraction and communication between dentists; 70% believed it could improve interaction and communication between dentists and patients; and 69% thought it would be helpful for patients in distant or rural locations. A similar percentage (72%) either agreed or strongly agreed with the potential enhancement merits of teledentistry for providingguidance/advice, clinical training, continuous education, and efficient referrals. More females (42%, p<0.001) than males (22%) agreed or strongly agreed that a teledentistry system would help monitor a patient's condition ( Table 3).

Capabilities to Improve Practice
Just under half of therespondents were unclear about their views concerning whether teledentistry is expensive to set up. More females (35%) than males (13%, p< 0.001) thoughtteledentistry would require additional appointments for imaging. Additionally, more females (36%) than males (14%, p< 0.01) were convinced that teledentistry could provide valid diagnoses comparable to those made in clinical settings (Table  4).

Security and Confidentiality
46% of the participants expressed uncertainty about technicalincompatibility. A series of chi-squared tests found that each item on the security and confidentiality ofteledentistry exhibitedgendered response patterns (p<0.05; Table 4). For example, 29% of female practitioners and 22% of male practitioners were very concerned about potential violations of confidentiality (p=0.0001), and 29% of females and 23% of males were a little or very concerned about the reliability of equipment and potential image forgery (p=0.001).

DISCUSSION
Although teledentistry is widely implemented in various dental fields across many countries, limited evidence is availableconcerningdentists' perceptionsabout adopting it in Saudi Arabia. The most conspicuous general observation arising from the present data is that dentists acknowledge teledentistry for its potential to enhance patient care and improve oral health practices. This confirms the growing interest in adopting telemedicine services [16 -18].These results are promising for future technological implications in dental screening and clinical diagnosis.Teledentistry is aimed to have a strategic importance in the future. In fact, this technology fits with other recently introduced improvements, such as CAD/CAM systems, which allow a digital workflow, with clinical reliability [18] and positive patients feedback [19].CAD CAM technology is easily linkable with telemedicine, and in dentistry, a completely digital workflow, from impression to final framework, is already viable in restorative dentistry, prosthodontics, and orthodontics [20 -21].
In Saudi Arabia, dental professionals prefer more traditional communication methods (i.e., phone calls and emails), and their least preferred modes of communication are video conferencing and forums. However, the flexible, diverse modes of telehealth are essentialforsupporting communication at a distance, especially for patients in rural and remote communities where healthcare access is usually inadequate.
Although technology provides modern and time-efficient methods to improve knowledge or facilitate work tasks, inthis study, dental practitioners used the internet for work-related purposes far less than for general information-seeking purposes. Further investigation is warranted to understand the possible reasons behind this finding.
Most participants agreed that teledentistry could optimize proper dental referrals. A high degree of accuracy was observed in several teledentistry studies when a digital intraoral photographic assessment method was compared with a direct visual examination in various clinical disciplines [23 -26]. Thus, teledentistry has great potential to reduce inappropriate referrals and shorten the waitlist for senior consultations [27,28].
Another factor associated with teledentistry modulation is thefinancial cost. Half of the sampled participantsagreed that teledentistry could potentially reduce costs, and two-thirds indicated that it could reduce unnecessary expenses incurred when traveling to hospitals. Evidence indicates that the cost associated with a teledentistry model of dental screening is lower than that associated with conventional, face-to-face dental screening in both rural and urban regions [29].The primary driver for net savings is linked to avoiding travel and accommodation and to the low salaries of dental therapists [30,31].Such savings could be redirected to improve infrastructure and provide much-needed oral health services to underserved patients.
The null hypothesis of this study was rejected, as gender was a significant variable influencing theacceptance and professional use of teledentistry.More female respondents agreed that teledentistry could help monitor patients' conditions, reduce cost, shorten waitlists, and prevent unnecessary travel to hospitals, especially in rural locations. Interestingly, female practitioners raised more concerns than male practitioners about patient confidentialityissues and the reliability of equipment associated with teledentistry practice. Females were also more convinced about the validity of diagnostic records, but, unlike the males, theybelievedteledentistry would necessitate additional appointments for photography.This confirms previous findings in the literature [10,32]. Although our results differ to some extent from those of Zhang [33],it could, nevertheless, be argued that the male gender imbalance ratio along with small sample size are the primary reasons for this rather contradictory result.Therefore, addressing gendered perceptions during teledentistry introduction mayhasten the public and private adoption of the technology.
The main limitation of this study is that it did not address thenon-technological, organizational, or political barriers associated with teledentistry. Self-selection into the study could also have biased the results; that is, those who were interested in teledentistry responded.More female practitioners were involved than males, and thus, conclusions drawn from the results must be made cautiously. The body of literature on teledentistry acceptance is also limited to the perceptions of itsend-usersandcare providers. There is not enough conclusive data on thecost-effectiveness and long-term use of teledentistry to make evidence-based policy decisions [31]. Further in-depth research is required to examine patients' acceptance of teledentistry.

CONCLUSION
Applying teledentistry in dental practice was generally well perceived by dental practitioners in Saudi Arabia. Gender differences in perceptions were linked to certain aspects of the efficiency and cost reduction of teledentistry. Although most dentists expressed positive opinions on teledentistry,female practitioners raised concerns about security and confidentiality.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Ethical clearance to conduct this study was obtained from the Research Ethical Committee of the Taibah University College of Dentistry , Saudi Arabia (TUCDREC2070209AL Harbi).

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All research procedures followed on humans were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION
A cover page was included in the questionnaire to summarize the study and provide the researchers' contact details for any research related queries. No personal information (names or telephone numbers) was required for participation. All data were collected into one database without differentiation, and information confidentiality was assured.

AVAILABILITY OF DATA AND MATERIALS
The data sets analyzed during the current study are available from the corresponding author [A.A] upon request.

FUNDING
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.