Telehealth technologies in care homes: a gap for dentistry?

Abstract

Background

Telehealth technologies are playing an increasing role in healthcare. This study aimed to review the literature relating to the use of telehealth technologies in care homes with a focus on teledentistry.

Methods

Khangura et al.’s (Evidence summaries: the evolution of a rapid review approach. Syst Rev 2012;1:10) rapid review method included an electronic database search on Embase, PubMed, Web of Science and OpenGrey. Out of 1525 papers, 1108 titles and abstracts were screened, and 75 full texts assessed for eligibility. Risk of bias was assessed using the Mixed Methods Assessment Tool 2018.

Results

Forty-seven papers (40 studies) from 10 countries, published 1997–2021, were included in the review, four studies related to teledentistry. Whilst some preferred in-person consultations, perceived benefits by stakeholders included reduced hospitalization rates (n = 14), cost-savings (n = 8) and high diagnostic accuracy (n = 7). Studies investigating teledentistry using intra-oral cameras reported that teleconsultations were feasible with potentially high diagnostic accuracy (n = 2), cost-savings (n = 1) and patient acceptability (n = 1).

Conclusion

There is limited published research on teledentistry, but wider telehealth research is applicable to teledentistry, with findings suggesting that telehealth technologies play a role in care homes consultations that are acceptable, cost-saving and with potential diagnostic accuracy. Further research is needed on the mode, utility and acceptability of teledentistry in care homes.

Introduction

In the United Kingdom, care homes provide accommodation and personal care for individuals who are ill/disabled, have mental disorders or dependent on alcohol/drugs,¹ with some providing nursing care. In England alone, there are 15 009 residential care homes,² with ~348 832 residents aged 65 years and over.³ Residents require additional care because of physical and/or learning disabilities, mental health issues or frailty, which makes them dependent on staff to carry out activities of general living (washing, dressing and feeding), as well as health care. As a result, residents are vulnerable individuals and often have difficulties accessing traditional face-to-face care.⁴ Barriers include transport for the resident/healthcare professional, healthcare professionals lacking familiarity with the resident, difficulty making suitable appointments and inability to access specialist care.^5,6 Teleconsultations can reduce these barriers by limiting travel and enabling residents to stay in familiar surroundings with support networks available, whilst providing access to virtual specialist advice.

Telehealth

Telehealth is the ‘use of telecommunications and virtual technology to deliver health outside of traditional health-care facilities’.⁷ Teleconsultations are an aspect of telemedicine involving remote consultations between patients and physicians using video technology. This can be beneficial to care homes in that it provides opportunities for quicker assessments, treatment prioritization, increasing access and a reduction to barriers to care.⁸ It includes real-time consultations (synchronous) where the patient and physician communicate via a video conferencing system, as well as store-and-forward (asynchronous), which involves information and images being stored and sent to the physician.⁹ The data can be used for diagnosis, developing treatment plans and referral to specialist. Studies have shown many uses and benefits of teleconsultations in care homes including reduced rates of hospital admission,^10,11 and assistance in care planning.^12,13 A 2017 systematic review suggested teleconsultations are beneficial in clinical assessment across various specialities but reported a sparsity of data on diagnostic accuracy and clinical support.¹⁴ Since the COVID-19 pandemic commenced, there has been an exponential increase in the use of telehealth¹⁵ in all healthcare settings. Alongside the use of teleconsultations, telemonitoring has also become increasingly utilized in the world of telehealth. However, telemonitoring has not been included in this review as it is a much broader area and does not always involve remote consultations.

Teledentistry

Care home residents often have poor oral health and as many are dependent, they rely on others for their oral care. Oral care guidelines placed by the National Institute for Health and Care Excellence (NICE) recommend supporting residents to access dental services, care staff use of oral assessments and oral health care plans, and staff training to deliver daily mouth care.¹⁶ The Care Quality Commission have been investigating the implementation of the NICE guidelines in care homes in order to improve oral health in care homes. Findings have been reported in the ‘Smiling Matters’ report and improvements are already being seen since 2019 with more care home managers being aware of the guidelines (40% in 2022 compared to 28% in 2019) and more care homes that have a full clear policy in place to promote and protect residents’ oral health (53% in 2022 and 25% in 2019).¹⁷ However, there was a decrease in residents who access NHS dental care routinely with 25% never accessing care in 2022 compared to 6% in 2019.¹⁷ This decrease is predominantly due to the COVID-19 pandemic. They also found that 25% of staff reported never receiving training in oral health care, and whilst this has decreased from 47% in 2019,¹⁷ it is still a large proportion of staff unable to provide adequate oral care.

One study found that nursing homes do not prioritize oral care and forgo brushing resident’s teeth even once a day.¹⁸ Many nursing home nurses feel that it is difficult to provide oral care to complex residents and that there is a lack of time to complete oral care.¹⁹ Care home residents also have difficulty accessing dental services due to limited mobility, transportation issues and long wait times.²⁰ Systematic reviews on teledentistry conducted before 2017 suggest that it could improve access to dental care.^9,21,22 Virtual technologies also offer an opportunity to support and train staff in oral health practices and facilitate advice and engagement with a dental professional when challenges occur for staff.

As a consequence of the COVID-19 pandemic, utilization of virtual technologies and remote prescribing has increased,¹⁵ with dental services forced to widely utilize it as the only means to provide care to their patients. This move has opened opportunities to implement teledentistry in care homes.

Given the pace of change and the potential for use of teledentistry, this review sought to review the use of telehealth including teledentistry in care homes.

Aims

To identify and appraise the literature relating to telehealth technologies in care homes with a specific focus on dental care.

Methods

This review was conducted according to the Khangura et al.²³ rapid review method, which enables descriptive analysis of qualitative and quantitative studies and large bodies of literature in a short timescale with rigour.

Search strategy

An electronic database search was carried out on PubMed, Embase, Web of Science and OpenGrey supported by library services. The search terms outlined in Fig. 1 were adapted to suit each database, shown in Appendices 1–4. A preliminary search found that there were little data on telehealth prior to 1997 compared to after, most likely due to the digital transformation and global internet access, as well as advancements and availability of technology, which was reflected in the search strategy, whereby the search was conducted for all work published between January 1997 and April 2023. Inclusion and exclusion criteria can also be seen in Fig. 1.

Fig. 1.

Search strategy including inclusion and exclusion criteria.

Screening

The completed search results were downloaded onto Rayyan QCRI²⁴ and duplicates removed. Following training and discussion with supervisors, a two-stage screening process was carried out by one reviewer (I.B.B.) firstly screening titles and abstracts, and secondly full texts. Records were excluded if they were systematic reviews, background articles, the wrong technology/intervention, the wrong population and the wrong publication type. Uncertainties were discussed with the second reviewer (R.P.). Disagreements were resolved in discussion with a third reviewer (J.E.G.).

Data extraction

Data extraction was conducted by one reviewer (I.B.B.) and 10% of records were checked by the second reviewer (R.P.). Data were extracted into a Microsoft Excel spreadsheet. Data items included

• Publication details: author, year, title, country, setting, population

• Aim/objectives

• Methods: study type, assessing, type of technology tested, evaluation, conditions/diseases

• Results: primary/secondary outcomes, type of technology, the effect of the remote consultation, key outcomes, conclusions

• Quality assessment: limitations, risk of bias, conflict of interest

Risk of bias

Risk of bias/quality was assessed using the Mixed Methods Assessment Tool 2018.²⁵ This assessment tool enables appraisal of all types of research (qualitative, quantitative, mixed methods, descriptive, randomized and non-randomized). In addition to this, papers are not given an overall score but are seen as a whole, which is beneficial for different study designs and for review questions where there is little available research.

Results

Out of a total of 1108 records, 47 papers and 40 studies were identified, as presented in Fig. 2. The characteristics of the included studies are shown in Table 1.

Fig. 2.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart, identifying the review process. Adapted from Page et al.²⁶

Table 1.

Characteristics of 40 included studies

Characteristics	All studies
Year of publication	1997–2021
Country, n  USA  Australia  Singapore  Canada  UK  France  Germany  Hong Kong  Portugal  South Korea  Multiple countries	18 5 5 3 2 2 1 1 1 1 1
Type of study design, n  Mixed  Randomized controlled trial  Non-randomized controlled trial  Cross-sectional  Descriptive  Cohort  Observational  Case–control  Other	9 5 5 3 2 2 2 1 10
Discipline, n  Geriatrics  Psychiatry  Dentistry  Dermatology  Mixed  Other	16 7 4 2 2 9
Outcomes, n  Acceptability  Hospitalization rate  Economic analysis  Diagnostic accuracy  Length of time for consultation  Quality of care  Clinical condition	21 14 8 7 7 6 3

In terms of quality, 16 = high, 18 = medium and 6 = low quality (Fig. 2; Appendix 6). Although referenced, studies were deemed low quality based on the MMAT criteria as they had incomplete data, small samples that were not representative of the population and did not account for confounders in the study design. The dental studies were of high quality. Multiple studies had loss of participants due to death, which is understandable given the population; however, this means that there is some bias as data were not always complete. Whilst many were pilot studies (n = 13), some had sample sizes that were not powered for even a pilot study.

The research had been conducted internationally across 10 different countries ranging from 18 studies in the USA to one study each in Germany, Hong Kong, Portugal and South Korea. Disciplines investigated include geriatrics (n = 16), psychiatry (n = 7), dentistry (n = 4), dermatology (n = 2), mixed discipline studies (n = 2) and others (n = 9). There has been a growing trend towards telehealth in care homes with most included studies being from the past two decades, suggesting an acceleration of research and practice in this field with peaks in 2001 and 2020 (Appendix 5). Most studies were quantitative (n = 31), followed by mixed-methods (n = 5) and qualitative research (n = 4). The findings are summarized in Table 2 by main outcome and discipline.

Table 2.

Summary of key findings

Study	Country, setting and population	Aims/objectives	Study design and discipline	Technology, methods and evaluation	Key outcomes	Authors’ conclusions	Quality assessment (MMAT)
Castanho et al., 2016	Portugal Mixed setting—local health centres, assisted living day-care centres and nursing homes 69 subjects, mean age: 74.33 ± 9.46 years	To use a videoconference approach of the Telephone Interview Cognitive Status Modified in different settings: (full-time community-dwellers, day-care centres and full-time residents in nursing homes) with diagnosed Alzheimer’s disease and compare the three different methods of administering cognitive screening in the same individual and across different settings/groups	Non-randomized, quantitative Reliability of assessing patients using teleconsultation technology compared to face-to-face consultations Psychiatry (neurological—cognitive function)	Synchronous Videoconferencing between the patient and psychologist over Skype Assessment results compared with face-to-face consultations	A strong association between the assessment used in videoconferencing and telephone, and the face-to-face assessment High accuracy for cognitive impairment discrimination	Videoconferencing may be as valid as telephone and face-to-face administration of cognitive tests Video conferencing may significantly aid in diagnosis and/or patient follow-up for this population	High
Catic et al., 2014	USA Long-term care sites 47 residents, mean age: 82 ± 12.6 years	To present the experiences and outcomes of designing and implementing an innovative, remote case-based video-consultation programme called ECHO-AGE that links experts in the management of behaviour disorders in patients with dementia to nursing home care providers	Pilot Feasibility Geriatrics	Synchronous Video consultations between the patient and specialist Results of the video consultation were recorded and analyzed	Clinical improvement of patients Significant difference between the number of patients who clinically improved when recommendations were followed and when they were not. This was linked to a significant decrease in mortality and reduced hospitalization	Some clinical improvement for patients when the recommendations were followed and a significant decrease in mortality compared to when recommendations were not followed	Medium
Chess et al., 2018	USA Skilled nursing facility Skilled nursing facility patients 313 videoconferencing encounters	To evaluate the effectiveness of an after-hours telemedicine-enabled coverage service	Non-randomized trial, service evaluation of technology Geriatrics	Synchronous Videoconferencing between the doctor and the patient (in the presence of a nurse). For physical examinations, a digital stethoscope and camera zoom are used. The doctor develops a working diagnosis and creates a care plan Data analysis of the medical and financial impacts from using the technology	Reduced hospitalizations, 83% of cases were treated on-site, 51% resulted in emergency department transfers and 18% reduction in the number of patients transferred to the hospital $1.55 million Medicare savings due to avoided hospitalizations	The use of a dedicated, virtual after-hours physician service resulted in reduced hospitalizations and a significant reduction in Medicare costs	Low
Cheng et al., 2020	Canada 26 long-term care facilities 32 patients, family members, 27 medical liaisons, 1 orthopaedic surgeon	To evaluate the utility of telemedicine in providing musculoskeletal (MSK) care to long-term care patients. The unique challenges facing the long-term care patients including mental status, mobility, transportation cost, family and caregiver’s ability to accompany and arranging for MSK care	Cross-sectional Satisfaction, acceptability Orthopaedics	Synchronous Teleconsultation carried out between an orthopaedic surgeon and a resident (some had family members present) Participants were surveyed for satisfaction and acceptability of the teleconsultation	High levels of satisfaction with both patients and liaisons. High-quality teleconsultations, improved accessibility to healthcare, good alternative to in-person consultations and reduced healthcare-associated costs	High-quality orthopaedic teleconsultations can be provided to nursing home residents with high patient and liaison satisfaction. It also has the potential to improve access to healthcare and reduce healthcare costs	Medium
Corcoran et al., 2003 Hui et al., 2001 Hui and Woo, 2002 Tang et al., 2001	Hong Kong Residential home for the elderly, nursing homes, and Care and Attention Home 1001 teleconsultations in total	To investigate the acceptability of using telemedicine in the diagnosis of foot disorders To assess the feasibility of telemedicine in providing geriatric services to nursing home residents, and whether this mode of care resulted in increased productivity and savings To explore the use of videoconferencing for service delivery to residential care homes To examine the feasibility, acceptability, costs, benefits and limitations of telepsychiatry	Comparison, accuracy of technology Podiatry Pilot, feasibility General resident care, dermatology, podiatry Pilot, feasibility Geriatric, psychiatry, physical therapy, dermatology, podiatry Pilot, efficacy Psychiatry	Synchronous Videoconferencing between the health care professional Results compared with those of in-person consultations Specialists completed questionnaires Patients completed satisfaction surveys Nurses completed questionnaires	For podiatry, 72% of diagnoses and 75% of treatment plans made by videoconferencing matched those made in-person Reduced hospital admissions, 85–92% of patients were in favour of telemedicine Accident and emergency department admissions reduced by 8.8% High feasibility for most disciplines, reduced wait times Time saving, reduced costs, and well perceived by staff and residents	Teleconsultations are feasible across multiple disciplines and helped increase access to care. Teleconsultations were also cost-saving and acceptable to healthcare professionals, nursing staff and residents	Low
Dorsey et al., 2010	USA A nursing home and the community 4 nursing home and 10 community participants aged 30+ years	To evaluate the feasibility of providing subspecialty care via telemedicine for patients with Parkinson’s disease residing in a remote community located ~130 miles from an academic movement disorders clinic	Randomized controlled trial, feasibility and accuracy Psychiatry/neurology (Parkinson’s diseases)	Synchronous Videoconferencing with patients for routine assessment, and motor examination Compared to gold standard (in-person)	Improvement of care and quality of life with high levels of agreement compared with the gold standard. Very high patient satisfaction and validity	Teleconsultations are feasible to provide access to specialty care for individuals with Parkinson’s disease for common assessments and examination with high reliability	Medium
Dy et al., 2013	USA Skilled nursing facility 23 skilled nursing facility subjects with a mean age of 83 years	To examine the feasibility and utility of teleconferencing to provide diabetes consultations for residents in a skilled nursing facility	Randomized controlled trial, pilot Other—diabetes	Synchronous Regular teleconsultations via Skype between endocrinologist, resident’s nurse, dietitian and family/residents to make care recommendations Compared with the glycaemic control of the intervention group	The proportion of residents who were hypoglycaemic and hyperglycaemic reduced in the intervention group and increased in the control group. The teleconsultations also allowed for changes to the treatment plan	The use of teleconsultations to provide diabetes consultations is feasible and can assist in improving glycaemic control for those in skilled nursing facilities	Low
Grabowski and O’Malley, 2014	USA 11 nursing homes Nursing home residents	To see if the residents of nursing homes that were randomly chosen to receive off-hours physician coverage by a telemedicine service experience a lower rate of hospitalization, compared to residents of homes that received standard physician coverage? And second, if the nursing homes with telemedicine coverage did have lower rates of hospitalization, did they realize substantial savings?	Randomized controlled trial Geriatrics	Synchronous Videoconferencing equipment and a high-resolution camera on a cart to be brought into the resident’s room for off-hours medical problems The number of residents hospitalized per month between intervention and control homes	No statistically significant effect compared to control but statistical reduction in hospitalizations in more-engaged telemedicine nursing homes than less-engaged nursing homes Fewer hospitalizations have cost-savings for Medicare for more-engaged nursing homes	Nursing homes that are more fully engaged in off-hours telemedicine coverage could have a reduction in hospitalization (compared to less-engaged nursing homes) and generate cost-savings for Medicare that exceed the facility’s investment in the telemedicine service	Medium
Grob et al., 2001	USA Nursing home 27 nursing home residents	To determine if standard rating scales including the Mini-Mental State Examination, Geriatric Depression Scale and Brief Psychiatric Rating Scale could be administered reliably via telecommunication in a population of nursing home residents	Case–control, comparison Psychiatry	Synchronous Subjects were assessed with 3 different psychological rating scales by a psychologist and the results were compared with those of an in-person assessment	There was no significant difference between patient assessment score using teleconsultations compared with in-person consultations; however, there was a lower reliability to assess visual behaviours	Remote assessment of patients using the structured psychiatric measures was reliable when compared with in-person assessment	Medium
Guilfoyle et al., 2003	Australia Rural aged-care facility 12 high-care residents, 6 male and 6 female	To determine both the feasibility of allied health professionals providing services to a residential aged-care facility using videoconferencing equipment, and users’ satisfaction	Non-randomized, feasibility Occupational therapy, physiotherapy, podiatry, speech pathology and dietetics (range of conditions)	Synchronous Residents were assessed by allied health professionals via videoconferencing and compared with in-person assessments with questionnaires and focus groups	Videoconference assessments were statistically significantly shorter than in-person assessment. More information could be obtained during in-person conferences. Overall, participants and health professionals had positive views on the videoconferences but with some issues	Videoconferencing was successful in assessing the allied health needs of high-care clients. Overall, allied health staff were optimistic about the potential of videoconferencing to complete assessments and felt that it would be particularly useful for consultations or in the initial stages of the assessment process	Medium
Hale et al., 2018	USA 11 community nursing homes Nursing home residents and staff	To (a) describe the implementation process of this quality improvement project delivering telehealth to geriatric Veterans; (b) explain facilitators and barriers encountered during implementation; (c) report utilization and cost measures; and (d) discuss the refined process and plans for sustainability of the VetConnect programme	Quality improvement, feasibility Geriatric	Synchronous Video calls from healthcare providers on clinic-based video telehealth tablets with headphones for hearing impaired Veterans. Comparison of pre-visit and post-visit clinical utilization, business and technical outcomes	Video visits between community nursing homes and Veterans Health Association providers are feasible based on completion of 203 visits across three subspecialties in 11 different community nursing homes, with technical success in the majority (83%) of visits over the 11-month implementation period of the Vet Connect project	The study found that the Vet Connect programme was good at providing specialty care in a timely and cost-effective manner	Medium
Helmer-Smith et al., 2020	Canada 18 long-term care homes 34 physicians, 18 nurse practitioners	To evaluate the feasibility of implementing eConsult in long-term care homes	Multi-method, quantitative descriptive, feasibility Geriatric	Synchronous Electronic consultation for primary care providers to communicate asynchronously with specialists concerning a patient’s care. Evaluated through consultation fata and focus groups	The eConsult service improved access to specialist advice, 70% of cases were resolved without the resident needing a face-to-face referral. A significant reduction in wait times to access specialist advice and significant savings	The study shows that it is feasible to implement teleconsultation with good referral times and outcomes. The focus groups had a positive response to the value of the service; however, participants did identify factors that would affect implementation including IT support, funding, staff resourcing and health records	Medium
Hofmeyer et al., 2016	USA Long-term care sites Long-term care residents	To assess residents from rural LTC facilities for potential transfer to hospitals	Pilot, efficacy Geriatric	Synchronous Two-way video and peripherals for real-time communication between residents and provides with on-call specialists. Two-way stethoscope and high-definition camera could also be used for remote examination. Compared the number of patients that needed to be transferred to a hospital and the number that did not	69% potential transfers were avoided, e-consultations can occur at varying times of the day and a decrease in transfer rate to 17% by 2015	The study shows promise and resulted in increasing utilization and reduction in unnecessary transfers to emergency departments and hospitalizations	High
Janardhanan et al., 2008 Lavanya et al., 2006	Singapore Nursing home 50 residents, mean age of 82 years 12 patients, 5 nurses and 2 dermatologists	To evaluate the usage and acceptance of the distributed personal health information management system (DPHIMS) and changes between Phases 1 and 2 To provide an overview on the clinical trial conducted, its results, and the usability and efficacy of the distributed Personal Health Information Management System (DPHIMS) for the management of healthcare for the senior citizens in skincare	Two-phase study for diagnostic ability and satisfaction Non-randomized clinical trial Dermatology	Asynchronous Images of the skin were sent to the dermatologist who made a likely diagnosis and treatment plan User satisfaction was evaluated through surveys and diagnosis through effectiveness of the treatment	High user satisfaction as they could see some benefits to the system for providing care remotely and reducing the number of in-person consultations and assisting patients in obtaining early treatment and regular follow-up at low cost The system improves the overall quality of healthcare. However, some felt that the medical care received via tele-dermatology was not as good as a conventional face-to-face visit	DPHIMS successfully demonstrated its potential for managing skin conditions at the nursing home in Singapore, avoided face-to-face and improved accessibility The survey results show positive responses to the system; however, some felt that conventional in-person visits provide better medical care then teleconsultations	Medium
Laflamme et al., 2005	USA Nursing home 35 nursing home residents with an average age of 60 ± 15 years, 3 clinicians	To pilot and assess the role of videoconferencing in clinicians’ medical decision-making and their interactions with nursing home residents	Pilot, non-randomized, acceptability Geriatric	Synchronous Videoconferencing between the participant and clinician for routine care and compared with in-person encounters	Clinicians’ responses about the utility of videoconferencing for making treatment decisions with nursing home residents were highly positive. There was also increased access to care	Videoconferencing without an in-person examination is sufficient for making medical decisions in most cases and feasible but in-person is preferred	Medium
Lee et al., 2000	South Korea 1 nursing home and 1 elderly welfare centre 2955 users including patients, doctors, nurses and family caregivers in a ratio of 4:4:4:1	To examine the acceptance and reliability of our telemedicine service and its clinical outcome to illustrate its specific significance and utility through our experience	Mixed-methods, comparative study Psychiatry/neurology (dementia)	Synchronous Specialist makes a diagnosis from clinical data and video interview with the patients and a treatment/care plan is provided Acceptance by users, consistency and clinical change were evaluated	Relatively high consistency rates in the ratings of cognition, dementia severity and in the diagnosis between assessment via teleconsultations and in-person assessment. Technical quality of calls was good. Behavioural symptoms of dementia patients were relatively improved	The telemedicine system seems to be a reliable modality for dementia assessment and effective for care of dementia patients	High
Low et al., 2019	Singapore 4 nursing homes Nursing home residents with a mean age of 76 years	To report a cost analysis of the programme from the healthcare system provider’s perspective	Cost analysis Geriatrics	Synchronous Teleconsultations using Polycom system where a trained nurse presents the symptoms to the geriatrician Cost variables: specialist outpatient costs, inpatient costs and ED and a regression analysis	Statistically significant cost-savings with for specialized outpatient costs and inpatient costs. Reduced hospital admission rate and emergency department transfers	Telemedicine consultations could reduce specialist outpatient clinic visits and hospital admissions in the nursing home setting, and therefore lead to cost-savings	High
Low et al., 2020	Singapore 8 nursing homes 850 patients, mean age of 77 ± 12.5 years	To describe the clinical workings of the GeriCare@North programme in terms of the patient profile and demographics, the presenting diagnoses, management provided and the processes involved in conducting the teleconsultation sessions	Prospective, descriptive Geriatrics	Synchronous Teleconsultations between the doctor and nurse and resident. Charts sent prior to the consultation Evaluated based on patient outcome 1 month post-teleconsultation	83.6% of consultations had patients remaining in the nursing home for continuing care by the nurses. Teleconsultations resulted in adjustment of drug regimen (57.3%), detailed monitoring including the use of nursing monitoring charts (35.4%), changes in medication dosage (27.8%), and skin and wound care management (13.5%)	The use of a simple videoconferencing system is highly feasible and could have a significant impact on the care of patients in long-term care facilities	High
Mass et al., 2001	USA Long-term care and rehabilitation facility 11 patients, mean age of 73 years	To determine the level of patient satisfaction, provider satisfaction and nurse satisfaction with using the telehealth system for consultation, assessment and care	Pilot, non-randomized, satisfaction Other—wounds	Synchronous, asynchronous Patients were brought to a teleconsultation room at the long-term care facility for assessment by the telehealth nurse expert. Telehealth nurse performed wound ratings and immediately after an on-site nurse performed wound ratings and the results were compared. Patients and nurses also completed a satisfaction survey	No clinical difference in the telehealth visit compared to on-site visit 70% of patients reported better understanding of their condition during the on-site visit compared to 40% for the telehealth visit. Slightly higher satisfaction for telehealth than on-site	The teleconsultations had similar clinical assessment results as in-person assessments. High levels of satisfaction from nurses and patients, similar to that of on-site consultations	Low
Mariño et al., 2014 Mariño et al., 2016	Australia Residential aged-care facility 50 residents 100 residents	To assess, the safety of the procedures, their feasibility, as well as patients’ and health practitioners’ experiences To compare the costs, from a public healthcare perspective, of face-to-face patient examination conducted by an oral health professional at residential aged-care facility with two alternative teledentistry approaches utilizing virtual oral examination to develop a treatment plan	Pilot, feasibility Cost analysis Dentistry	Synchronous, asynchronous Intra-oral camera operated by a registered nurse, files either transmitted to the oral health professional or operated in real time to the oral health professional Comparison with in-person examinations as the gold standard Cost in developing a treatment plan compared to in-person	The intra-examiner agreements for dental examination parameters determined by the Kappa index reflected an ‘Excellent’ agreement (Kappa = 0.83). Technical feasibility and acceptance, by both users and residents The asynchronous model is always the model with the lowest cost, compared to both the real-time and the conventional face-to-face models	Teledentistry is an appropriate alternative to traditional oral health consultation and could provide benefits to an expanding segment of the population in relative and absolute terms When a registered nurse is trained in the manipulation of an intra-oral camera and data handling, the asynchronous model is always the model with the lowest cost, compared to both the real-time and the conventional	High
Newbould et al., 2017	UK Care homes, residential homes 124 responses from home managers	To explore the use of videoconferencing to access health care in care homes, identifying levels of knowledge, attitudes and views towards videoconferencing in the region	Descriptive, acceptability survey Geriatrics	Synchronous Videoconferencing between patient and physician Evaluation through surveys and semi-structured interviews of GPs and nursing home staff in homes that used videoconferencing and homes that did not	For the nursing homes that already use telemedicine, 67% said they use it less than once a week, 17% said less than 3 days a week and 8% once a year. Benefits include care closer to home; could provide the best route to the ward/department so speeding up access to health care	Healthcare professionals have positive perspectives of the potential use of telemedicine in the care home and benefits were better understood there were still concerns	Medium
Ohligs et al., 2020	Germany Retirement home 38 residents, mean age of 83	To develop a user-orientated, integrated telemedical system for pre-existing doctor–patient relationships. Focus was placed on the feasibility of a structured video anamnesis and physical examination through telemedically connected devices in nursing homes. Focus was also placed on the evaluation of this system’s acceptance by GPs and elderly patients	Multi-layered, feasibility Geriatrics	Synchronous Videoconferencing between patients and physicians with vital sign diagnosis Questionnaires to evaluate perspectives and results of the teleconsultation	Medical decision-making including diagnosis and therapy were rated as ‘easily feasible’ in 98% of all cases and ‘not time-consuming’ in 96% of cases. Overall high acceptability and feasibility	The telemedicine approach had high acceptance and feasibility particularly due to the integrated medical devices, which provided valuable information for practitioners to make a diagnosis	Low
Pallawala and Lun, 2001	Singapore 2 elderly homes 72 residents, nursing staff and physicians	To implement a feasible telegeriatric medical service with the use of the state-of-the-art technology to deliver medical services efficiently to remote sites where elderly homes are based	Qualitative feasibility, acceptance Geriatric	Synchronous, asynchronous Clinical data are uploaded onto the system and can be viewed by the specialist prior to the consultation with the patient, and after the consultation a management plan is uploaded and sent to the elderly home Perceptions of nursing staff, hospital staff and patient were evaluated	High levels of feasibility, perceived reduction in hospital admissions and transfers and high levels of satisfaction amongst nurses, doctors and patients	The TeleGeriatric system has feasibility at providing quality consultations with high satisfaction and care outcomes	Medium
Perri et al., 2020	Canada Long-term care home 61 residents, mean age of 87 years	To evaluate whether the integration of early palliative care specialist consultation into a long-term care home would be feasible through the implementation of videoconferencing during routine interdisciplinary resident care conferences	Mixed-methods, pilot satisfaction Other—palliative care	Synchronous Interdisciplinary care conference with a palliative care specialist integrated remotely via videoconference Stakeholders’ opinions were evaluated for using teleconferencing to discuss palliative care	Videoconferencing showed acceptability in terms of supporting team communication, introducing palliative concepts to the clinical team earlier in illness trajectory. Most clinical staff and families were satisfied with the videoconference and were willing to use it again, but families would still prefer to see their palliative care specialist in person. There was a significant increased staff confidence and increased comfort in discussing and providing palliative care to residents and using telemedicine	The study supports feasibility of early integration of palliative care specialist services through videoconferencing and improved access to the palliative care approach in long-term care homes. Early integration of palliative care specialist services into a long-term care home through videoconferencing also led to improved self-rated confidence in the palliative approach to care by clinical staff and families	High
Petcu et al., 2017	France 9 long-term care facilities, 2 specialized facilities 135 patients	To provide access to an oral consultation for the elderly in France and to assess the patient’s perception of the oral teleconsultation procedure	Observational, residents’ behaviours Dentistry	Asynchronous An intra-oral camera takes images and videos of the oral cavity, which are then sent to the hospital’s dentist who makes a diagnosis and decides on an intervention Resident’s acceptance of the nurse using the intra-oral camera was measured	Psychotic patients perceived the teleconsultation more as a negative than a positive experience. Nonpsychotic patients had an overall positive experience, which became less pronounced as one moved from autonomous to semi-autonomous and on to dependent patients	Most patients completed the procedure with overall more positive reactions than negative reactions to the use of the intra-oral camera for examination	High
Piau et al., 2020	France 10 long-term care facilities 90 residents	To evaluate health workers’ perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities	Open-label, non-randomized trial Neuropsychiatry	Synchronous Teleconsultations led by a geriatrician and nurses for evaluation and diagnosis of neuropsychiatric symptoms Evaluation through interviews before and after implementation of teleconsultations to see if the views of the long-term care facility staff had changed	An increase in positive responses after the intervention. Increased perception of weakness after but decrease in potential threats. Better interdisciplinary team communication and cohesion	Results reveal positive long-term care facility staff perceptions regarding telemedicine influence on the healthcare system, staff work and staff consideration, and the quality of care	Medium
Queyroux et al., 2017	France, Germany 8 nursing homes 237 residents, mean age of 84.4 years	To evaluate the accuracy of teledentistry for diagnosing rehabilitation status of dental prostheses, and evaluating dental pathology, assessing the nursing homes (using direct examination as a gold standard)	Cross-sectional, diagnostic accuracy Dentistry	Asynchronous Examination of the oral cavity using an endoscope and sent to dentist for analysis Comparison of dental diagnosis via video recording versus face-to-face consultations	Diagnosis made from video recordings had high specificity and sensitivity when compared to the gold standard (in-person) and were faster by an average of 8 min. 95.3% acceptability rate amongst residents and family members	Teledentistry has excellent accuracy for diagnosing dental pathologies, and good accuracy for assessing the rehabilitation of dental prostheses and chewing ability amongst older adults living in nursing homes	High
Rabinowitz et al., 2010	USA Nursing homes 106 nursing home residents, mean age of 77.5 ± 13.6 years	To describe the development and implementation of a nursing home telepsychiatry consultation service and the benefits associated with its use	Cost analysis Psychiatry	Synchronous A two-way interactive video consultation for nursing home resident and nurse (sometimes family member) with the psychiatrist Costs analyzed	If nursing home residents were transported to a psychiatrist’s office for consultation, a minimum of more than $13 000 could be saved by providing the nursing home consultations by telepsychiatry. If the physician visited the patient, the maximum cost-savings could be greater than $232 000	The most important benefit of the telepsychiatry consultations is that many of the nursing home residents evaluated and treated would have received no psychiatric care at all. This is due to cost-savings, time saving and travel savings	High
Samara et al., 2021	Australia 28 care homes 421 residents	To test whether conducting telehealth Needs Rounds and case conferences is as effective as face-to-face during COVID-19 Continue to improve the quality of life and death through the Needs Rounds model and access to specialist palliative care	Quality improvement, pilot Other—palliative care needs	Synchronous Weekly needs rounds via telehealth live video calls from nursing home staff to GPs Telehealth needs rounds effectiveness compared to face-to-face	Telehealth Needs Rounds and case conferences are as effective as face-to-face for identifying residents at risk of dying and planning for end-of-life care	Telehealth is as effective as face-to-face delivery of needs rounds. Telehealth needs rounds increase access to specialist palliative care services and can be conducted during a pandemic	High
Shah et al., 2013	USA Senior living communities (independent and assisted) White women with a median age of 92	To assess patients’ and caregivers’ experiences with telemedicine-enhanced care, providers’ and staff members’ experiences in providing telemedicine-enhanced care, and stakeholder-perceived barriers to and facilitators of the programme	Qualitative evaluation Other—acute illness	Synchronous Certified telemedicine assistants collect history and examinations (electrocardiograms, phlebotomy, point-of-care testing) and sent information to the provider for review. An in-home telemedicine visit could then be carried out Semi-structured interviews with individuals from each stakeholder group to assess the experience of using the telemedicine intervention	Telemedicine was not viewed as superior to in-person care, but it provided enough data for a level of diagnostic certainty to improve clinical care	Stakeholders found the convenience and speed of telemedicine-enhanced emergency care to be highly desirable. Providers felt that telemedicine-enhanced emergency care provided enough data, enhanced diagnostic certainty and, overall, improved care, even though they felt in-person visits to be superior	High
Shah et al., 2015	USA Senior living community 1537 senior living community residents, mean age of 85 years	To assess the effect of a high-intensity telemedicine programme for senior living community residents on the rate of emergency department use for ambulatory care sensitive conditions (ACSC)	Cohort study, perspective feasibility Ambulatory care sensitive conditions	Synchronous, asynchronous Video and audio communication, images, videos, sound and 12 electrocardiograms for patient–provider communication when patient feels ill Compare rate of emergency department visits between participants using the high-intensity telemedicine for acute illness care and the control group	No statistically significant difference in change of ACSC emergency department visits over time between the intervention and the control group but a statistically significant effect within the intervention group (34% reduction, compared with no reduction in the control group)	Providing acute illness care by high-intensity telemedicine to older adults residing in SLCs significantly decreased the rate of emergency department use for ACSCs over 1 year by 34% compared with none amongst the control group but no statistically significant difference between the intervention and control groups (P = 0.06)	High
Toh et al., 2015a Toh et al., 2015b	Singapore 2 nursing homes, 3 nursing home partners Nursing home residents with an average age of 75 years, majority Chinese 25 nurses, nurse managers, hospital geriatricians and administrators	To assess if increased level of engagement with telegeriatrics translates to lower hospital admissions To explore the perspectives of users from the nursing homes and the acute hospital on two	Comparative Descriptive Geriatrics	Synchronous Two-way live video consultation with the nurse presenting the residents’ symptoms to the geriatrician and the nurse can conduct a basic clinical assessment guided by the geriatrician who will then prescribe an appropriate treatment Hospital admission rates were compared over 5 years (before telegeriatrics and during) for more-engaged and less-engaged nursing homes 7 focus groups and 2 semi-structured interviews carried out to assess staff perceptions	There was a statistically significant decrease of 35% in the hospitalization rate for the more-engaged nursing home and the hospitalization rate for the less-engaged nursing home was similar to that of control facilities The programme reduced the need for unnecessary travel and provided timely diagnosis and treatment. The users identified with the benefits of using telemedicine to manage residents remotely and improve clinical outcomes, and hence avoid emergency department visits	Telegeriatrics showed potential in reducing unnecessary hospital admissions amongst nursing home residents. The early identification of clinical issues and access to specialist support provided alternatives to use of the emergency department. It could contain costs with resident outcomes Overall, the positive attitudes made it possible to coordinate treatment plans for patients on-site and to strengthen nurses’ knowledge and skills in providing better nursing care. Shared decision-making enabled the nurses to demonstrate ownership for their practice, and empowered them to manage their practice with a greater degree of professional autonomy	Medium
Tynan et al., 2018	Australia 6 residential aged-care facilities and 3 multi-purpose health services that include residential aged-care beds 116 residents 46 residents	To look at alternative ways to deliver a more effective oral health service to residents To investigate the impact and experience of an integrated teledentistry approach to oral health compared to current standard care within regional and rural residential aged-care facilities	Quality improvement Mixed-methods comparative study Dentistry	Synchronous Live stream of the oral cavity recorded using a probe by an Oral Health Therapist, to the Dentist Dentist decides on a treatment plan to complete or require an in-person appointment The impact of the integrated oral health programme compared to no integrated programme	Increased access to oral health care, increased awareness of residents’ oral health needs and prevention requirements and observed savings in minimizing need to transport resident to an oral health facility Improving access to oral health education for aged-care staff and preventative health care for residents; minimizing disruption to residents, especially those with high-care needs	The integrated oral health programme showed potential to improve the oral health outcomes and benefit high-care residents (those with dementia and other cognitive and physical disabilities). The increased support and training opportunity will benefit facilities without easy access to oral health services	Medium
Vowden and Vowden, 2013	UK Nursing homes 26 residents, 5 nurses	To establish whether digital pen-and-paper technology, digital photography and mobile phone technology could be effectively utilized to transmit sufficient wound data to allow a remote specialist in wound care to provide support to local health professionals working in nursing homes thus enhancing care and improving outcome for this vulnerable and elderly patient group	Randomized controlled, pilot Other—wound care	Asynchronous Wound images were taken using a smartphone camera and these data were electronically linked to the digital paper form and sent on a secure server to the remote nurse consultant for assessment Comparison of wound care with a control group	TeleWound system allowed early recognition of deterioration and prompt appropriate action taken to prevent further deterioration, improved compression therapy, reduced number of visits and improved the patient’s quality of life with immediate pain reduction	TeleWound system has potential to improve wound care for residents	Medium
Wade et al., 2015	Australia 3 residential aged-care facilities 5 residential aged-care facility staff, 4 general practitioners, 3 residents	To provide video consultations between general practitioners and residential aged-care facilities, to see if it was possible to provide faster access to medical care and avoid unnecessary hospital transfers	Qualitative descriptive Geriatrics	Synchronous Videophones and iPad minis were used to have video consultations with the general practitioners The number of video consultations, implementation issues, technical implementations were evaluated	Implementation of the teleconsultation was difficult with facilities being not having enough technical capacity and knowing the protocol for video consultations. Some positive feedback for potential use but also negative for delivery. The rate of billable consultations was low, averaging one a fortnight with 7.5% avoiding a hospital transfer	Challenging to make video consultations a routine method of delivering general medical services to long-term care facilities	Medium
Wakefield et al., 2004	USA 2 veterans affairs medical centres and 1 long-term care facility 12 physicians, 30 nurses and 62 residents	To assess provider and resident satisfaction with and outcomes of specialist physician consultations provided via interactive video to residents of a long-term care centre	Cross-sectional, survey Geriatrics	Synchronous Interactive video conferencing between specialty physicians and residents with the nurse present utilizing electronic medical equipment (electronic stethoscopes, lights, cameras) Written surveys conducted after the telemedicine visit for evaluation	72% did not require on-site visits for treatment. Overall, physician ratings were positive. 81% of resident evaluations and 99% of nurse evaluations indicated satisfaction with the telemedicine consultation process. Physicians noted that telemedicine consultations can be useful for follow-up care, but none recommended it for the initial patient consultation	Whilst the video consultations did reduce the number of residents who needed in-person treatment/consultations and there was overall high satisfaction, physicians felt that in-person consultations would be better for initial examinations and then telemedicine would be better for follow-up care	High
Weiner et al., 2003	USA Nursing home 6 physicians, 369 residents	To determine how often videoconferencing was useful and which medical conditions in the nursing home were most likely to lead to videoconferencing	Randomized trial Geriatric	Synchronous Portable, wireless videoconferencing workstation brought to patient’s bedside for communication with the on-call physician Physicians asked to rate the usefulness of each episode of videoconferencing and the impact of videoconferencing on medical decision-making and resident’s healthcare. Participants were asked about their opinions on videoconferencing	Physicians and residents seemed accepting of the telemedicine programme and the videoconferences were useful for changes in mental status, abnormal laboratory values and falls	Both physicians and residents of a nursing home accept unscheduled videoconferencing	Medium
Yeung et al., 2009	USA Nursing home and hospital 9 residents, all monolingual Chinese immigrants	To explore the feasibility, acceptability and usefulness of telepsychiatry services to elderly Chinese immigrants who live in a nursing home in the USA	Observational, pilot Psychiatry	Synchronous Videoconferencing between nursing home residents and the psychologist Feasibility determined by whether the subject showed up and participated in one or more videoconference for follow-up after the initial in-person psychiatric consultation. Participants were surveyed for satisfaction	Many of the nursing home residents were open to being interviewed using videoconferencing. Teleconsultations were effective in guiding and supporting nursing home staff in handling residents. Patients, their families and the nursing staff expressed high levels of satisfaction	It is possible to use telepsychiatry to provide services to minority immigrants in nursing homes. Has the potential to improve access to care for minority patients	Low
Zelickson and Homan, 1997	USA Nursing home 29 residents	To examine a still-image store-and-forward tele-dermatology system for use in the care of nursing home residents	Pilot, non-randomized comparative Dermatology	Asynchronous Images of cutaneous findings were taken and sent to the dermatologist via the still-image telephone along with the patient history and a diagnosis and treatment plan would be made. Within 48 h an on-site consultation and a diagnosis and treatment plan would be made Comparison of diagnosis and treatment plan made in the teleconsultation compared to the correct diagnosis from the on-site consultation. Cost analysis performed based on time spent by the nurse collecting and sending patient information and dermatologist consultant fees	More than 85% of cases were able to be accurately diagnosed and treated with the tele-dermatology system. Skin lesions more easily diagnosed than skin eruptions where 8 cases were left unable to be diagnosed. Physicians felt more comfortable making diagnosis and treatment plan when an image was available with 5 incorrect diagnoses and 4 incorrect diagnoses with eruptions	Tele-dermatology consultations can replace some on-site consultations in a cost-effective manner with high diagnostic accuracy	High

In terms of outcome, studies focussed around four key areas: diagnostic accuracy, acceptability, efficacy and economics.

Telehealth

Seven studies considered diagnostic accuracy with mixed results when compared to face-to-face care. Neurological disorders and psychiatry using real-time consultations found high consistency in assessment scores determined between teleconsultation and in-person consultations,^27–30 with some difficulties due to a lack of reliable informatics and radiologic examination.³⁰ Dentistry and dermatology predominantly utilized the asynchronous approach and found statistically significant results for level of agreement, accurate diagnoses, sensitivity and specificity.^31–33

Acceptability was considered in 21 studies for the perspective of healthcare professionals, care home workers, patients/residents and family members. There was generally a positive view on the use of teleconsultations from all stakeholders,^{4,6,13,30–32,34,35} particularly when increasing access to care, reducing hospital admissions, and reduced travel and wait times.^{6,13,30,34,36–42} Teleconsultations were less accepted when the technology was inefficient,^{4,28,39,41,43} and by residents who were more difficult/had lower cognitive abilities.^37,44 There was a general view that in-person care would be preferred over remote care.^{4,36,37,39,41,45–47}

The efficacy outcomes differed depending on the study. Fourteen studies found that overall, the rates of hospitalization reduced with a teleconsultation intervention.^{10,11,38,48–58} Length of time of teleconsultations were found to be less than that of in-person consultations.^{6,10,13,32,39,45,59}

Eight studies considered economic analysis, and findings suggest teleconsultations offered cost-savings from all aspects of health care.^{10,11,49,51,54,55,59,60} Several studies in the USA found savings from reduced hospitalisations and travel costs.^49,55,59

Teledentistry

Only four studies (six papers) investigated teledentistry, three of high and one of medium quality. All the studies involved the use of intra-oral cameras or similar. Two studies used both the synchronous and asynchronous consultation methods, one study only used synchronous consultations and the final only used the asynchronous method. One study reported excellent intra-examiner agreement between in-person and teleconsultations, with a Kappa value of 0.83,³¹ and another found high sensitivity and specificity of the technology for diagnosing dental pathologies (93.8 and 94.2%, respectively), assessing chewing ability (85.0 and 82.8%, respectively) and rehabilitation status (87.8 and 90.3%, respectively).³²

When investigating residents’ acceptance of a nurse using the intra-oral camera for the teleconsultation, one study found that overall residents responded more positively than negatively.⁴⁴ Whilst 76% of residents reported some difficulty in keeping their mouths open (dependent patients having the most difficulty), 69% of residents were not opposing at all during the procedure.⁴⁴ However, more dependent or psychotic residents had increased difficulties with the remote consultations with 28% not cooperating. A further study reported that residents generally found it easy to understand the remote communications with 46% finding it ‘very easy’, another 46% ‘easy’ and 4% were neutral and 28% found that the most valuable element of the teleconsultation was the convenience.³¹

By utilizing teledentistry for oral health therapy screening, 12% of residents were prevented from needing to travel to an oral health facility, and following teledentistry screening only 28% of residents required a teledentistry review and 16% required an in-person appointment.⁶¹ The teleconsultations also showed potential to improve awareness of residents oral health needs and improving support to manage residents,⁴² with the number of residents with oral health care plans increasing from 53 to 96%.⁶¹

One study found that the asynchronous model was cost-saving and real-time consultations were of a similar cost to in-person consultations, with 71–76% of the total costs of teledentistry being associated to the provision of oral examination and treatment plan development.⁶²

Discussion

Main findings of this study

Synchronous and asynchronous teleconsultations in care homes used for assessment, follow-up and management were reported with improved quality of care,^{5,12,13,48,50,61,63–65} and access to care^{5,6,13,30,34,36–41,46,53,55,60} across telehealth and teledentistry.

Although potential cost-savings were found in wider healthcare, involved with reduced travel costs and reduced costs for each consultation,^{10,11,49,51,54,55,59,60} there was little data on cost-savings in dentistry. In addition, it should be noted that the studies were conducted across 10 different countries, with varying health systems, levels of maturity of digital landscapes and regulatory environments. Furthermore, the papers lacked detail on the approach to economic analysis; therefore, the inference of these findings to the UK is limited.

Stakeholders expressed high levels of satisfaction with teleconsultations,^{4,6,13,30–32,34–47,66} although in-person consultations were preferred.^{4,14,36,39,41,45–47} However, related to dentistry, there was only one study, and it was specific to the acceptability of the use of intra-oral cameras. A number of studies found that teleconsultations reduced the rate of hospital admissions,⁴³ and improved quality of care as assessment and treatment plans/care plan changes were implemented more efficiently.^5,12,48 This was also reflected in the limited teledentistry studies^42,63 with reported increased awareness and oral care planning.

Conflictingly, although some research carried out for psychological/neurological conditions suggested that effective communication was possible through teleconsultations with individuals with additional needs or lower cognitive function,^27,29 other research found issues with the utility of telehealth modalities in the same patient groups.^37,44,50,66

Several studies suggested teleconsultation technology would be better used with follow-ups as opposed to diagnosis^13,27,36 due to the difficulties faced with physicians not conducting the physical examinations themselves,³⁷ and technical difficulties,^{4,39,41,43,47,58} which increase visit time, prevent decision-making and decrease satisfaction.⁴¹ With people in the UK going into care later in life and with more complex comorbidities, the true utility and acceptability of teledentistry is an area that requires further investigation.

What is already known on this topic

Previous systematic reviews reported similar findings on telehealth consultations in care home settings, including reduced hospital admission rates,¹⁴ high diagnostic accuracy,⁶⁷ the ability to develop and implement treatment plans,¹⁵ and the inclusion of family members and care home staff in care discussions.¹⁴ Furthermore, teleconsultations were associated with improved access to care,^15,67 as well as cost-savings for all stakeholders involved, with reduced travel costs and reduced costs for each consultation.^14,67

What this study adds

This review, which is the first to include dentistry in the wider context of telehealth consultations, highlights the limited research undertaken in the field of teledentistry and significant gaps in the knowledge. From the limited research undertaken, the findings from the teledentistry studies are largely in line with wider telehealth papers, with challenges around the quality of video conferencing and images using a telecamera for diagnostic potential and traditional consultations remaining the preferred choice. This review provides a broader evaluation of the use of telehealth across a range of disciplines and highlights the usefulness of research and potential opportunity for teledentistry in care settings. Research on teledentistry is in the top 10 priorities for the National Institute for Health Research to consider, ⁶⁸ so whilst there was a paucity of research on teledentistry, the findings from other disciplines offers insight into the evolving teledentistry model of care. Results suggest that the use of intra-oral cameras to take images and videos of the oral cavity, to send to a dentist or oral health professional, may have high diagnostic accuracy when compared to in-person consultations,^31,32 where clinical examination involves positioning, light, for visual diagnosis supported by other aids.

Overall, the findings from 16 high- and 18 medium-quality studies suggest that the utilization of telehealth consultations is beneficial and the initial research in relation to dental and oral care is promising, particularly for pre-assessment and follow-up. However, it is important to note that the utilization of telehealth consultations is not yet a replacement for face-to-face clinical care, which needs to be delivered by the dental team, using the relevant equipment, but an assistance to overall dental care.

Limitations of this study

There are limitations in this research related to the search strategy. Only records written in English were included, which limited the search; this included all the grey literature. Part of one study was French and could not be included so some data may be missing, and a large proportion of the studies were pilot studies (n = 13) and feasibility studies, so it is difficult to compare teleconsultations against in-person consultations. A further limitation is that the term telemonitoring was included in the search terms and it yielded a large volume of studies in relation to wearable monitoring devices, which had to be excluded during screening. There are also challenges with the heterogeneity of the studies included in terms of location, and analysis conducted. Furthermore, none of the studies considered the underlying digital literacy amongst the social care workforce, or patient population, nor do they consider the regulatory aspects, equipment or infrastructure challenges of a digital landscape.

Conclusion and recommendations

The rapid review provides evidence of high to medium quality that telehealth technologies in care homes for consultations are considered acceptable, cost-saving, reduce barriers to care and offer potential diagnostic accuracy and improved care. Studies mostly from pilot studies, non-randomized controlled trials and feasibility studies provide promising evidence that telehealth is beneficial to care homes and residents as an alternative to face-to-face care, across a range of disciplines. However, some studies found difficulties without conducting physical examinations, residents with low cognitive function, and poor technology/equipment. Overall, teleconsultations were shown to have great potential to care planning/follow-up rather than physical examinations or assessments with some evidence of diagnostic accuracy when used for neurological or psychological real-time assessment or with dentistry and dermatology using the asynchronous approach.

Although teleconsultations may prove a useful adjunct to existing dental care models, they are not a replacement for face-to-face clinical care that needs to be delivered by a dental team, using the relevant dental equipment. Further research is needed on the acceptability, digital literacy and maturity of teledentistry, as well as the infrastructure and latency of emerging technologies.

Nevertheless, it is imperative that with the current challenges presented to accessing dental care,⁶⁹ and the rising use of telehealth post-pandemic, innovative dental care models should be explored alongside and as part of existing traditional care models. These should be coproduced in partnership with social care, to ensure fair, equitable and timely access to both routine and urgent dental care for this complex patient group residing in an ever-changing social care landscape.

Ishmyne B. Bhamra, Former MSc Dental Public Health student

Jennifer E. Gallagher, Global Envoy King’s College London, Newland-Pedley Professor of Oral Health Strategy/Honorary Consultant in Dental Public Health

Rakhee Patel, Senior Clinical Lecturer, Honorary Consultant in Dental Public Health

Funding

None declared.

Conflict of interest statement

None declared.