Facilitating dental disease screening program in prisoners using an intraoral camera in teledentistry

This study was a cross-over design conducted in Sisaket Prison and Sisaket Primary Health Care Institution, Thailand. The male prison in Sisaket Province was chosen for data collection because the number of prisoners and PHVs was higher than that in the female prison. Therefore, male prisoners and PHVs were eligible to participate in the study. Exclusion criteria were prisoners with a history of violent behavior and unwillingness to undergo oral examination by medical staff. This research project was approved by the Human Research Ethics Committee of the Sisaket Provincial Public Health Office (ethics number: SPPH 2022-045) and was conducted in accordance with the Helsinki Declaration of Ethical Principles of Medical Research Involving Human Subjects. All participants agreed and signed an informed consent form before participating in the study.

The dental disease screening program has three phases:

Phase 1: PHV Teledentistry Training Program

Phase 2: Dental disease screening using teledentistry

Phase 3: Oral examination by dentist and assessment of dental treatment needs

The second phase of teledental screening is planned for August and September 2022. The flow chart of participant inclusion in the second and third stages is shown in Figure 1 .

figure 1

Flowchart of participant inclusion.

In Thailand, PHVs are voluntary prisoners selected by the warden and receive a good time allowance. They must be illiterate and at least graduate from primary school. PHVs must complete a 25-hour health training program that includes oral health knowledge and practices [11]. PHVs acquire basic knowledge in caries risk assessment, oral hygiene practices, food and nutrition, screening for oral diseases and their risk factors, and more. They must be able to identify possible treatment needs, including fillings, root canals, scaling, simple tooth extractions, and surgical removal of affected teeth.

Caries detection and assessment follows the International Caries Detection and Assessment System (ICDAS) [13], with a score ranging from 0 to 6. Teeth with an ICDAS score of 3 to 5 and patient complaints of tooth sensitivity, toothache, cavities, or darkening indicate the need for fillings. Teeth with an ICDAS score of 6 and patients complaining of cavities or fractures accompanied by severe or sudden toothache indicate the need for fillings, root canal treatment or tooth extraction. However, since there is no X-ray machine in the prison, it is impossible to distinguish whether a tooth needs filling or root canal treatment through X-ray examination. For prisoners, extraction will be the only treatment option for ICDAS 6 teeth, rather than root canal treatment. This is because teeth with extensive cavities may require root canal treatment, while endodontically treated teeth require prosthetics such as posts, cores, crowns, which are not a viable treatment option for prisoners due to their expense and time consumption. .

Criteria for required dental cleaning using the Simplified Oral Hygiene Index [14]. Symptomatic non-cavitated teeth with supragingival calculus covering more than one-third of the teeth, or subgingival calculus around the cervical one-third of the teeth, indicate the need for dental cleaning. Impacted teeth, usually third molars that are unable to erupt vertically and may be covered by soft tissue, are indications for surgical extraction when patients complain of toothache or cavities.In accordance with evidence-based practices established by the American Association of Oral and Maxillofacial Surgeons, affected third molars should be extracted or regularly monitored for the development of disease or pathology, even if they are currently asymptomatic [15]. However, in this study, which only included prisoners with dental problems, all affected third molars were symptomatic and indicated the need for extraction.

Phase 1: PHV Teledentistry Training Program

Eight of the 45 male PHVs in Sisaket Prison volunteered to participate in the one-day, three-hour “PHV Teledentistry Training Program.” The PHV was trained to use an intraoral camera or IOC (Portable Waterproof HD Video USB Oral Mirror, China), the imaging tool used in this remote dental project (Figure 2) [16]. IOC can take pictures with a resolution of 2 million pixels. The light source composed of 6 LED bulbs provides 3 levels of brightness with a visual distance of 2-4 cm. The camera can connect to a computer or Android smartphone via Universal Serial Bus (USB 2.0) or microcontroller (microC) and transmit data, displaying images with resolutions of 1600 × 1200 and 1280 × 720 pixels respectively. While images can be transmitted from the IOC using Wi-Fi or cellular connections, these systems are not available in prisons. Therefore, in this study, images from the IOC were stored and synchronized to the VideoLAN Client (VLC) media player program, which is a free application available for Windows, iOS, and Android systems. In order to use IOC in prison, open the VLC program on your computer. After intraoral photos are taken, the images are stored in the VLC program in a folder created specifically for each prisoner. Only designated nurses have the authority to transmit images via Google links or Excel sheets and send them to dentists in primary care centres.

figure 2
figure 2

Intraoral scope for teledentistry.

The dentist used 30 intraoral photographs containing dental caries and periodontal disease to calibrate the PHV and determine possible treatment options. The PHV must achieve a Kappa value of at least 0.80 to agree with the dentist's diagnosis and then be allowed to proceed with data collection in the second phase. There is only one computer in the Sisaket prison office that can be connected to the IOC. Therefore, one trained male PHV was randomly selected through random numbers to participate in the second phase of the teledentistry program.

Phase Two: Screening for Oral Health and Treatment Needs Using Teledentistry

Of a total of 1,621 male prisoners, 309 were willing to use teledentistry for dental disease screening. PHV conducted face-to-face interviews with prisoners. Information about the prisoners was recorded, including their demographics, systemic illnesses and dental-related problems. 157 prisoners with dental-related problems identified problem areas in their mouths, and PHV used IOC to capture potential symptom areas. The camera tip is covered with plastic wrap. After each patient examination, the plastic wrap is discarded and the IOC tip is wiped with a small towel soaked in disinfectant for disinfection (CaviWipes)TM value) for 3 minutes, wipe with 70% alcohol solution and cover the tip with new plastic wrap. Inmates' information and intraoral photographs were recorded on Google Forms with links to dentists in the primary care cluster.

After the teledental screening program, the PHV and dentist independently determine the tentative dental treatment need for each tooth based on intraoral photographs and the patient's symptoms. Treatment needs include fillings, scaling, extractions and surgical removal of affected teeth. The dentist also provides each inmate with an initial treatment plan for subsequent dental treatment appointments.

Stage 3: Oral examination and dental treatment needs assessment directly by the dentist

Another dentist who did not participate in Phase 2 conducted direct oral examinations of inmates who complained of tooth-related problems. Document dental treatment needs for each tooth, including fillings, scaling, extractions, and surgical removal of affected teeth. On the day of the examination, some prisoners underwent simple tooth extraction surgery at the prison's mobile dental clinic. Other required dental treatments are provided later at the primary care centre.

Research the power of computing

Power analysis of sample size was calculated using the G*Power version program and was based on two-sided 95% confidence intervals for a single proportion using an exact test series. Based on an effect size of 0.17 and a sample size of 157, the reported prevalence (proportion of observations) of dental-related problems was 0.50, achieving 98.6% power.

data analysis

Data analysis was performed using SPSS program version 28.0. Descriptive statistics were used to demonstrate means (± standard deviation, SD) and frequencies (percentage, %). For diagnostic testing, PHVs and dentists calculated four values ​​from the distal dental examination: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). True-positive cases were determined based on direct oral examination by a third-stage dentist. The treatment needs determined by PHVs using teledentistry were compared with the treatment needs determined by dentists using teledentistry and other dentists' direct oral examinations.

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