Discussion

Oral health of the PNSC is a public issue of concern in many countries since people with special needs constitute about 15% of the world’s population. ¹⁵ According to the 2002 National Disability Survey, disabled persons constitute 12.29% of the population in Turkey. ¹⁶ When compared to their healthy counterparts, PNSC are more vulnerable to poor oral health and face barriers accessing oral health care services. Thus, significant gaps occur between oral health status and accessing oral health care services for this special population. ^{Reference Glassman, Harrington, Namakian and Subar2,Reference Olivier, Thibault and Stéphane3} In the study of Dorin et al., ^{Reference Dorin, Moysan and Cohen17} it was found that among 8401 children and teenagers with disabilities, only 3.4% have no oral disease. The teledentistry approach poses a reliable option nowadays to bridge this gap and increase ease of access of quality oral care, reducing and/or eliminating the costs of transportation. Furthermore, teledentistry could possibly be more appropriate for PNSC than in-person visits because patients can have the examination in their home with their caregivers. ^{Reference Olivier, Thibault and Stéphane3,Reference Inquimbert, Malthierry and Arzens9,Reference Christensen and Bezyak12,Reference Langkamp, McManus and Blakemore18}

In medicine, the use of telemedical applications has had promising outcomes for the PNSC where most of the participants with special needs had a positive opinion regarding health care delivered via telemedicine. ^{Reference Harper6,Reference Zhou and Parmanto11,Reference Christensen and Bezyak12,Reference Lindgren, Wacker and Suess19} In the era of dentistry, however, limited evidence was present regarding the efficacy of teledentistry applications in the PNSC. In this study, we aimed to explore the feasibility and acceptability of teledentistry from patient/parent and clinician perspective in PNSC admitted to our department. A recent national survey in 2020 indicated that 79% of Turkish citizens between ages 16 and 74 years used the Internet, and 89.9% of them used a broadband connection; 86.9% of them had access to the Internet via a mobile broadband connection. Also, the rate of cell phone/smartphone usage was reported to have reached 98.7% in 2019. ²⁰ Therefore, we performed virtual examinations via video calls by means of smartphones. We prefer the mobile teledental approach via the WhatsApp application because the application is simple, has large-scale usage, is suitable nearly for all smartphones, requires no costs, and has obvious benefits in terms of privacy in the health care setting. ^{Reference Hogan, van Hees, Asiedu and Fuller21,Reference Hughes, Stallard and West22}

In this study, none of the participants had used the telemedical approach before in the medical or dental specialties. Most of the participants, both F and IE groups, reported being satisfied with the teledentistry approach performed via video calls and reported having used this tool to take the examination again. However, nearly half of the participants have concerns regarding the efficacy of remote examination when compared to face-to-face visits. The clinician who performed the examinations reported “accuracy of examination” as least satisfactory and found this approach more effective in F patients when compared to the IE patients. These results may have originated from the lack of standardization in terms of technical infrastructures that the participants used and also the lack of knowledge of the patients regarding remote care. Despite these concerns, our findings also suggest that this approach could be useful to facilitate oral care delivery if it is improved.

A remote oral diagnosis for the PNSC has been researched in a teledentistry project named e-DENT, which was conducted in France. In the e-DENT project, a caregiver or a nurse used an intraoral camera with fluorescence to record information for teledentists who performed the diagnosis. For a similar group of patients, another project named TEL-E-DENT, also conducted in France, used an endoscope to record information of the virtual examination. In these 2 projects, more than 4000 patients have been diagnosed. The participants found this approach less stressful and cost-effective. Nurses/caregivers who participated in the projects found the approach useful. Also, dentists reported that teledentistry is a useful tool to connect directly with patients/caregivers, and it is very useful making a first evaluation. ^{Reference Olivier, Thibault and Stéphane3,Reference Giraudeau, Roy and Malthiery4,Reference Inquimbert, Malthierry and Arzens9}

In Australia, the teledentistry approach for diagnosis and consultations of the underserved, high-risk population with major oral health needs was explored by comparing face-to-face examinations and remote examinations using an intraoral camera. A total of 50 individuals participated and it is suggested that teledentistry is a feasible and reliable alternative to traditional methods, in particular, for oral health screening. Participants reported high satisfaction with the teledentistry approach. ^{Reference Mariño, Hopcraft and Tonmukayakul23} Also, another project known as Virtual Dental Home (VDH) in California uses telehealth technology so that dental personnel in the community could communicate with dentists in dental offices/clinics as well as the interdisciplinary teams for education, triage, preventive care, and early intervention for underserved groups of children and adults. The project has shown that, with this approach, more patients can receive care, and without additional costly infrastructure this model can better adapt oral care into health care. ^{Reference Glassman, Harrington, Namakian and Subar2} It is difficult to compare the results of the present study with the previous researches conducted in the PNSC because of the difference regarding the designs and the populations. Regardless of the teledentistry service formats, a high satisfaction rate in the present study echoes the results of the previous research. ^{Reference Giraudeau, Roy and Malthiery4,Reference Inquimbert, Malthierry and Arzens9,Reference Mariño, Hopcraft and Tonmukayakul23}

Telemedicine can be applied in a synchronous (real time) or asynchronous (store-and-forward mode) manner. ^{Reference Estai, Kanagasingam, Tennant and Bunt8,Reference Marino and Ghanim24} In a systematic review about the telemedicine applications among rural individuals with disabilities, it was reported that generally videoconferencing was used for synchronized intervention, in which local care providers, patients, caregivers, and the remote care team could interact in real time. High satisfaction was observed among caregivers with the usage of this method. However, in some instances when a disabled patient does not cooperate in real time, asynchronous telehealth may be preferred since patients are more likely to cooperate when having a medical exam done alone by a person they know. ^{Reference Christensen and Bezyak12,Reference Langkamp, McManus and Blakemore18} Regarding telehealth service modes, such as m-Health or mobile health care, Jones et al. ^{Reference Jones, Morris and Deruyter25} reported in their systematic review that disabled users indicated a 40% adoption rate of m-Health apps. In this study, a video call via WhatsApp was successfully used for the examination of the patients in real time for most of the patients. Only 12% of the patients had difficulty using the application during examinations.

Impairment of people’s access to dental health care is an important consequence of the disasters and emergencies such as the COVID-19 pandemic. In this way, teledentistry can bridge access to health care services by avoiding disruptions while allowing the vulnerable populations to remain safely at home during utilization of the remote care. Therefore, teledentistry would be a valuable care option for vulnerable populations during disasters/public health emergencies.

This study has some limitations that should be considered when interpreting the results. Although the small sample size is a limitation, this is a pilot feasibility study. Another limitation of this study was the lack of standardization regarding the quality of video-calling, which was affected by smartphones. In the present study, only a physician performed and evaluated video consultations. The WhatsApp application used in this study is not a specific application designed for a telemedical approach.

Teledentistry is considered a highly effective approach, comparable with face-to-face visits, which enhances an early diagnosis and referrals, and transcends social and geographic barriers. This practice reduces the costs for patients without increasing costs to the oral health provider as well as avoiding inappropriate referrals and preventing backlogs to waiting lists. ^{Reference Christensen and Bezyak12,Reference Nesbitt26,Reference Vigil, Kattlove and Calouro27} However, barriers such as issues related to reimbursement, lack of knowledge about this option among patients, the costs and maintenance of telehealth equipment, and ensuring patient privacy prevent the wider implementation of this approach. ^{Reference Harper6,Reference Nesbitt26,Reference Vigil, Kattlove and Calouro27}