Identifying the requirements for the implementation of teledentistry in rural areas: A scoping review protocol

Abstract

Oral health disparities in rural areas of developing countries are exacerbated by geographic barriers, limited infrastructure, and workforce shortages. Teledentistry, a branch of telemedicine, offers a promising solution to improve access to dental care. This scoping review aims to identify the infrastructure, workforce, and patient-related requirements for implementing teledentistry in rural settings. In this scoping review, Arksey and O’Malley’s five-stage framework will be used. PubMed, Web of Science, Scopus, and Embase databases will be used to search for studies using a detailed search strategy. Using specified inclusion and exclusion criteria, studies that focus on identifying the challenges of implementing teledentistry in rural areas, and were published between 2004 and 2024, will be identified and reviewed. An interdisciplinary team will develop search strategies, and two researchers will independently review eligible studies for final study selection. Finally, the data will be extracted and categorized to enable statistical analysis of the results. Only English-language studies will be included due to resource constraints. Two independent reviewers will screen and select studies, with data extracted using the MAXQDA 2020 software. This review will map key requirements for teledentistry implementation, guiding policymakers and practitioners in designing effective programs to enhance dental care access in rural areas.

Introduction

Oral health is a critical component of public health, influencing overall well-being and quality of life.[1] Globally, oral diseases affect approximately 3.5 billion people, with untreated dental caries being the most prevalent.[2] Tooth decay can cause pain, inflammation, bleeding gums, abscess formation, and chronic infections in the body, and these oral infections can cause systemic diseases such as heart problems, strokes, and respiratory diseases.[3] Despite the WHO’s emphasis on oral and dental health and the importance of oral health on the quality of life, we see an increase in the index of tooth decay in low to middle-income countries, especially in areas where preventive programs have not been implemented. Therefore, it is necessary to evaluate primary prevention strategies and implement health promotion programs, especially in remote and rural areas.[4] Various studies show that the rate of tooth decay in rural areas is much higher than of urban residents.[5] According to the results of Tahani’s research in evaluating the oral health status and oral and dental health behaviors in the nomadic adult population, the rate of tooth decay among the nomads is 40.9% and tooth loss is due to decay in 55.9%. Lack of access to health services in the rural population, was mentioned as a potential reason for this problem. Rural populations face significant barriers to dental care, including geographic isolation, limited infrastructure, and a shortage of dental professionals.[6] For instance, in Iran, over 60% of provinces have fewer than 500 dentists, most of whom are concentrated in urban centers.[4] These disparities contribute to higher rates of dental caries and tooth loss in rural areas, with studies reporting a 40.9% caries prevalence among nomadic populations.[7] With the emergence of new technologies such as high-speed internet, video conferencing and digital equipment, remote health equipment can be used in various forms such as: providing health care services, diagnosis, consultation, treatment, education, care management and patient self-management using electronic audio communication, and two-way visual benefit in the field of health and reduce household expenses to some extent.[3] Telemedicine is also used to solve problems such as unequal access and lack of infrastructure, and eliminate the challenges related to geographical, fiscal, and physical requirements for delivering services in remote and underserved areas.[8] Teledentistry is a new branch of telemedicine which consists of a collection of electronic patient data that communicates through the internet between health service providers and people seeking these services, and provides basic knowledge about care and improvement of dental health This facilitates the efficient exchange of information and knowledge between the patient and the doctor and between different specialists to achieve better treatment planning and outcomes.[9] In the last few years, the COVID-19 pandemic has created an important challenge in health care systems around the world. This disease was transmitted through respiratory particles and direct contact with an infected person. Since the face-to-face and close interactions of health care professionals with a person infected with the corona virus increases the risk of transmission to the disease, so dentists were more exposed to the corona virus than other medical specialties that many developed and developing countries have distanced from teledentistry in They used this epidemic period.[10] Unlike traditional dental care, teledentistry enables consultations, diagnostics, and education through video conferencing, phone calls, or text-based platforms, making it a viable solution for underserved areas.[11] This scoping review uniquely focuses on synthesizing requirements for teledentistry implementation in rural areas, addressing infrastructure, workforce, and patient-related factors. While prior studies have explored technical aspects of teledentistry, this review adopts a comprehensive approach to inform policy and practice in low- and middle-income countries. Figure 1 presents a conceptual framework for teledentistry implementation, encompassing three dimensions: infrastructure (internet access, equipment), workforce (training, skills), and patient acceptance (cultural attitudes, awareness). This framework guides the scoping review to systematically identify barriers and facilitators.

Figure 1.

Conceptual framework for teledentistry implementation

Objective

This study aims to identify the infrastructure, workforce, and patient-related requirements for implementing teledentistry in rural areas of developing countries.

Review team

The review team consists of experienced researchers with backgrounds in health service management, health policy, epidemiology and dentistry.

Materials and Methods

Study design and setting

Studies published in English between 2018 and 2024, addressing teledentistry in rural settings, will be included. Non-English studies are excluded due to translation limitations. The population includes rural residents, with subgroups such as children, the elderly, and low-socioeconomic groups. This scoping review will be conducted according to the key concepts and requirements for the implementation of teledentistry in rural areas around the world. Then, the study will be conducted based on the main keywords [Table 1] obtained by conducting preliminary review studies and consulting with experts, in English scientific databases (PubMed, Web of Science, Scopus). This review will be guided by the five-stage framework proposed by Arksey and O’Malley. The five key steps of this scoping review are as follows:

Table 1.

Keywords and specified databases and websites

Concept/context		Keywords/terms
Oral hygiene		Dental health OR oral health OR oral Diseases OR oral Disease OR oral disease OR dental disease
Teledentistry		Teledentistry OR Televisit OR Telcommunication OR Tele triage OR tele diagnosis OR tele health
Database		Search strategy syntax		Filters
PubMed		(((“Teledentistry “[Mesh] OR “ teledentistry “[All Fields] OR “ Televisit “[All Fields] OR “ Telemedicine “[All Fields] AND “Dental remote”[All Fields] OR “ Telcommunication “[All Fields] OR “ Tele triage “[All Fields] OR “ tele diagnosis “[All Fields] OR “ dental health “[All Fields] OR “ oral health “[All Fields] OR “ oral Diseases “[All Fields] OR “ oral Diseases “[All Fields] OR “ oral Disease “[All Fields] OR “ dental Disease “[All Fields]) OR (“dental Disease “[Mesh] OR “remot visite”[Mesh] OR “remot dental diagnosis”[Mesh].assessment”[tiab] OR “resilience planning”[tiab]))		2018–2024 English
Web of science		(“Teledentistry “ OR “ teledentistry “ OR “ Televisit “ OR “ Telemedicine “ OR “ Dental remote “ OR “ Tele triage “ OR “ Dental remote “ OR “ Telcommunication “ OR “ Tele triage “ OR “ tele diagnosis “ OR “ dental health “ OR “ oral health “ OR “ oral Diseases “) OR “ dental Disease “ OR “ dental Disease “ OR “ remot visite “ OR “ remot dental diagnosis “
Scopus		TITLE-ABS-KEY (Teledentistry “ OR “ teledentistry “ OR “ Televisit “ OR “ Telemedicine “ OR “ Dental remote “ OR “ Tele triage “ Telcommunication “ OR “ Dental remote “ OR “ Telcommunication “ OR “ Tele triage “ OR “ tele diagnosis “) AND TITLE-ABS-KEY(“Dental remote “ OR “ tele diagnosis “ OR “ dental health “ OR “ oral health “ OR “ oral Diseases “) OR “ dental Disease “ OR “ dental Disease “ OR “ remot visite “ OR “ remot dental diagnosis

1. Defining the research question in a structured format.

2. Systematic search and identification of studies most relevant to the research question.

3. Screening and selecting studies that align with the research topic.

4. Data extraction and analysis of the selected studies.

5. Summarizing and reporting the findings.

The study will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), as recommended by Tricco et al.[12] This framework will ensure the systematic identification, analysis, and reporting of key insights.

Framework for step one: Defining the research question

What are the main questions of the research “requirements for implementing teledentistry in rural areas in different parts of the world”?

In this study, we are looking for concepts in a specific topic, and words should be chosen that describe the most detailed topic and are aligned with the PCC framework (P: population), (C: concept), (C: context).[13]

Population

This study will focus on the population of rural areas, including sub-population groups such as children, the elderly, and people with low socioeconomic status.

Concept

This study focuses on the provision of remote services including diagnosis, consultation, and education of patients using communication technologies

Context

The research area will include areas with low population density, limited access to health services, and geographic challenges in low- and middle-income countries.

Framework for step two: Determining databases and relevant keywords

At this stage, after determining the databases, the keywords related to the research topic were determined by reviewing the texts and the opinions of experts in this field, and then searching in PubMed, web of Sciences, Scopus and Embase will be performed. The above databases will be examined for a period of 20 years (2004 to 2024). Also, related specialized websites and scientific associations, and relevant organizations such as the WHO will also be searched.

Framework for step three: Screening and selecting relevant studies

After a comprehensive search with the determined strategy [Table 1] in the specified databases and websites, according to the research question, all the obtained articles will be entered into the Endnote software. Screening and selection of articles after removing similar and repetitive items in the software and taking into account the inclusion and exclusion [Table 2] is performed through the following steps:

Table 2.

Inclusion and exclusion criteria

Inclusion criteria		Exclusion criteria
English language		Non-English language
Studies covering data from 2018 onwards		Studies only covering data earlier than 2018
Studies published from 2018 onwards		Studies published before 2018
Studies focused on Identify the requirements for remote dental practice		Studies that, upon full-text review, are determined to be outside the scope of our concept and research context
Study design: All relevant quantitative and qualitative studies		Study design: scoping reviews
Access to full-text		Not access to full-text
Publication types: (a) journal articles, (b) health reports, (c) guides, instructions, and implementation methods		All studies and guidelines that, upon full-text review, are found not to align with the research aim and questions
Publication status: published		Publication status: pre-print

Initial screening

The articles will first undergo initial screening based on their titles and abstracts to evaluate their relevance to the research question.

Full-text screening

After the initial selection, the full-text articles will be thoroughly reviewed, and the final eligible studies will be selected. To ensure strong agreement between reviewers, the selection criteria will aim for a Cohen’s kappa coefficient of over 75%. Any changes to the inclusion criteria during the process will be updated accordingly, and any disagreements will be collaboratively discussed and resolved.[14] Additionally, the reference lists of included studies will be reviewed to identify other potentially relevant studies in the field. Manual searches using relevant keywords will also be conducted in Google Scholar to include studies that may not have been indexed in the searched databases. Furthermore, experts in the field will be consulted to identify any additional relevant publications that may not have been captured through the database search.

Framework for step 4: Data extraction and information processing

At this stage, by reading the full text of the selected articles, the relevant information is extracted and then entered into the Excel software to be analyzed. A form will be designed to extract data from eligible articles, which includes information such as author, publication date, type of study, and study characteristics (such as geographic location, geographic scale, target population, methods, data, and indicators used in the study). This set of information allows us to specify the comprehensive nature of the research under review in the next stage of the framework. Two researchers will independently extract the data. If necessary, if no agreement is reached on the selection of articles, a third researcher will also be involved. In addition, a qualitative thematic analysis approach will be employed to describe the included articles to categorize and present key themes in the data.

Framework for step five: Summarizing and reporting results

At this stage, after extracting and recording the information of the selected articles in Excel software, matching the findings, summarizing and final report will be presented in a written table. Our goal is to develop a new conceptual framework to support systems thinking methods that help us identify the requirements for implementing teledentistry in rural areas. Finally, the findings and their implications for future research in planning policies and practices will be discussed. Qualitative evaluation of the studies included in this research will not be performed, because the purpose of our review is not to provide evidence data or causal relationships, but rather to clarify the concepts and identify the requirements for implementing teledentistry in rural areas. It is worth mentioning that to avoid bias and increase credibility, each of the search processes in different databases, extracting documents, preliminary review of documents, matching with inclusion and exclusion criteria is performed by two researchers independently. In cases where there is a difference of opinion between two researchers, the review of the article will be performed by a third person to reach a consensus.

Study participants and sampling

Studies published in English between 2018 and 2024, addressing teledentistry in rural settings, will be included. Non-English studies are excluded due to translation limitations. The population includes rural residents, with subgroups such as children, the elderly, and low-socioeconomic groups.

Deta collection tool and technique

A comprehensive search strategy [Table 1] was developed with input from experts in health services management and dentistry. Databases (PubMed, Scopus, Web of Science) and relevant websites (WHO) will be searched. Keywords include “Teledentistry,” “Rural health,” “Telemedicine,” “Telemedicine,” “Dental Care,” “Health Services Accessibility,” and “dental care.”

Ethical consideration

All participants will be fully informed about the aims of the study and their rights, including the right to withdraw at any time without any consequences. Before participation, both verbal and written informed consent will be obtained from all participants. Confidentiality and anonymity of personal information will be strictly maintained. Ethical approval will be obtained from the Ethics Committee of the University of Health Sciences before the commencement of the study.

Data analysis

Data analysis was conducted using MAXQDA 2020 software. Extracted data from the standardized form [Table 3] were imported into MAXQDA for systematic coding and qualitative analysis. Two independent reviewers performed the coding process, targeting study characteristics, geographic context, and teledentistry requirements (infrastructure, workforce, and patient factors). Inter-rater reliability was ensured with a Cohen’s kappa coefficient >0.75, and discrepancies were resolved by a third reviewer. Data analysis was carried out concurrently with data collection, utilizing MAXQDA’s tools for thematic coding, content analysis, and pattern identification. Advanced features, such as co-occurrence analysis and conceptual mapping, were employed to explore relationships between variables and derive meaningful insights from the data.

Table 3.

Data extraction form

Field		Description
Author		Lead author name
Year		Publication year
Study type		Qualitative, quantitative, mixed-methods
Location		Country/region
Infrastructure		Teledentistry infrastructure requirements
Workforce		Teledentistry workforce requirements
Patient-related		Patient-related factors for teledentistry
Notes/comments		Additional remarks or discrepancies

Discussion

This scoping review will identify critical requirements for implementing teledentistry in rural areas, addressing gaps in infrastructure, workforce training, and patient engagement. The use of a systematic scoping review framework, following Arksey and O’Malley’s methodology, and the involvement of a multidisciplinary team with expertise in health services management, health policy, and dentistry enhance the study’s rigor and comprehensiveness. Recent studies highlight the importance of high-speed internet and trained dental professionals for successful teledentistry programs.[15] For instance, a study published in the Journal of Education and Health Promotion demonstrated that online training significantly improved dentists’ confidence in adopting teledentistry.[16] Additionally, the COVID-19 pandemic underscored teledentistry’s value in minimizing infection risks during dental consultations, reinforcing its relevance in resource-constrained settings.[17] However, the reliance on secondary data may limit insights into real-world implementation challenges, such as practical barriers faced during teledentistry deployment in rural settings. Future research should explore cultural influences on teledentistry acceptance and evaluate cost-effectiveness models for rural settings.

Limitations and recommendations

Limiting the review to English-language studies may exclude relevant non-English research, particularly from developing countries. Additionally, variations in teledentistry definitions across studies may complicate comparisons.

Conclusion

This scoping review will provide a comprehensive overview of the requirements for implementing teledentistry in rural areas, informing health policy to reduce oral health disparities. By identifying infrastructure, workforce, and patient-related needs, the findings will guide the development of sustainable teledentistry programs in low- and middle-income countries.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.