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Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 360-364

Assessment of mother's ability in caries diagnosis, utilizing the smartphone photographic method

Department of Public Health Dentistry, Dr. D.Y. Patil Vidyapeeth, Dr. D.Y. Patil Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication7-Nov-2019

Correspondence Address:
Dr. Sonal Kale
Department of Public Health Dentistry, Dr. D.Y. Patil Vidyapeeth, Dr. D.Y Patil Dental College and Hospital Pimpri, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_349_18

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Background: Smartphone is proved to be reliable in teledentistry model. The aim of the study was to assess the mother's ability in caries diagnosis, utilizing the smartphone-based photographic method. Hypothesis: Mothers have the ability for caries diagnosis utilizing the smartphone photographic method. Methods: A cohort of 100 mothers was given health education regarding dental caries diagnosis. Then, their children from the preschools were screened by the dentist for dental caries using visual examination, followed by clicking intraoral photographs using Motorola 3G phone. The photographs were sent through WhatsApp to respective mothers, and they were asked to diagnose their child's dental status. Accuracy and reliability measures of mother's diagnosis were estimated by calculating the sensitivity, specificity, predictive values, and kappa value. Results: The calculated value for sensitivity was 88.3%, specificity was 98.3%, positive predictive value was 92%, negative predictive value was 97%, and accuracy was 96%. There was a strong agreement between mother's and dentist's diagnosis (kappa value of 0.87). Conclusion: Following the dental health education, it can be concluded that mothers are in a better position to diagnose their child's dental status through smartphone-based photographs.

Keywords: Children, dental caries, mother's diagnosis, smartphone, WhatsApp

How to cite this article:
Kale S, Kakodkar P, Shetiya SH. Assessment of mother's ability in caries diagnosis, utilizing the smartphone photographic method. J Indian Soc Pedod Prev Dent 2019;37:360-4

How to cite this URL:
Kale S, Kakodkar P, Shetiya SH. Assessment of mother's ability in caries diagnosis, utilizing the smartphone photographic method. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Dec 1];37:360-4. Available from: http://www.jisppd.com/text.asp?2019/37/4/360/270482

   Introduction Top

Dental caries is a preventable oral disease. If measures are not taken in the initial stages, it will advance to a level in the children where it can cause pain, low self-esteem, premature tooth loss, and damage to the erupting permanent teeth.[1] This is also one of the reasons for the loss of school hours among children worldwide. A study [2] reported that children miss around 6 days of school in a year due to dental problems hampering their academic performance in schools while the parents too are not spared as they miss around 2.5 workdays a year due to their child's dental problems. This scenario is because of the lack of awareness regarding dental health of children among both urban and rural people [3] and also because of avoiding dental treatment due to the long span of waiting time [4] at clinics. To overcome these barriers, teledentistry approach can be of great use to parents to address their child's oral health.

Teledentistry is an approach which acts as a new medium of educating the community with the help of technologies like smartphone.[5] Many studies have been conducted in the field of teledentistry which enlightens the ease and reliability of this technology-based approach as compared to our traditional techniques which are being followed from years for diagnosing a disease. Estai et al.[6] conducted a study to evaluate the efficacy of remote screening for dental caries using smartphone camera and reported a specificity and sensitivity of 97%–98% and 60%–68%, respectively. Amável et al.[7] reported that the remote diagnosis of children dental problems based on noninvasive photographs constitutes a valid resource for early diagnosis and maintaining appropriate oral health among children. Inbuilt camera of mobile phone is proved to have high-quality images over intraoral camera, and smartphones are found to be easy to operate and handle as compared to digital single-lens reflex camera.[8]

Smartphones have proved to be reliable in teledentistry models. Literature [9] is available wherein self-screening has been done to diagnose oral cancer and precancerous lesions among adults. If smartphone technology is combined with dental knowledge, it can be hypothesized that mothers can play a vital role in screening their child's mouth for dental caries. Hence, the present study intended to combine dental health education along with diagnosis through a smartphone. The aim of the study was to assess the mother's ability in caries diagnosis, utilizing the smartphone-based photographic method.

   Methods Top

The hypothesis of the study was “Mothers have the ability for caries diagnosis utilizing the smartphone photographic method.” The study was conducted in the month of January 2018 in the two preschools of Pimpri, Pune. Ethical approval was obtained from the Institutional Ethics Committee of Dental College and Hospital before starting the study (Ref No. DYPDCH/IEC/1262/30/17). Convenience sampling method was used for including the mother and children in the study. Sample size of 100 was calculated through the past literature [10] keeping the allowable error of 10%. Children aged between 3 and 5 years, whose parents gave written informed consent for their child's participation and their mothers who were regular users of WhatsApp, were included in the study.

The study was conducted in three phases.

Phase 1

It was initiated with obtaining permission from the preschools and obtaining consent from the parents. A cohort of 100 mothers was given dental health education regarding normal dentition and decayed teeth, caries appearance in the oral cavity, and signs and symptoms and its diagnosis. The session lasted for 20 min and was conducted in two batches. A color  Atlas More Details was used for education which contained pictures of normal dentition and dentition with dental caries. This atlas was used as reference by the mothers for diagnosing caries in the photographs (any blackish/brownish deviation in the appearance of normal tooth was supposed to be called as caries with reference to the color atlas). The dentist (SK) underwent training and calibration in clicking intraoral photographs (three images) with Motorola third-generation smartphone by adjusting the focus to obtain a sharp and clear image along with the use of inbuilt flash. A distance of mobile phone from that of the mouth was kept in a range of 18–20 cm to obtain a clear image and also to avoid unnecessary contact of the gadget with the skin of the child. To ensure intra examiner reliability, ten children were re-examined, and also intraoral photographs were taken.

Phase 2

Oral visual examination was carried out by the dentist (SK) for the identification of dental caries using mouth mirror and probe and artificial illumination. Dental caries assessment criteria: the WHO 1997 criteria were used for denoting a tooth as carious.[11] Following oral examination of each child, three photographs of their dentition (the first photograph displaying maxillary occlusal surface of teeth, second photograph displaying mandibular occlusal surface of teeth, and the third photograph displaying labial surface of maxillary and mandibular teeth together). After 1 week of dental health education, the photographs of the respective child were sent to the mother for caries diagnosis.

Phase 3

Mothers were asked to look into the photographs which were sent on their WhatsApp and identify the carious teeth in their child's mouth.

Statistical analysis

Data obtained from the dentist and the mother's diagnosis were collected and entered onto a Microsoft Excel spreadsheet 2007. Analysis was performed using online calculator [12] for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. Percent agreement between dentist and mother's diagnosis was calculated using kappa value. Chi-square test was applied to check if there existed any significant difference in the diagnosis made by the dentist and the mothers.

   Results Top

Oral examination was conducted for 100 children in the age range of 3–5 years (4.1 ± 0.63). Dental caries prevalence found in this group of children was 78%. A total of 300 photographs were clicked with 100 of maxillary dentition, 100 of mandibular dentition, and 100 of maxillary and mandibular together to capture front teeth [Figure 1]. There were no missing teeth present in any of the child, and thus, total teeth examined were 2000 (20 teeth per child). Intraexaminer reliability value for intraoral photographs was 100% and for clinical examination was 80%. True-positive, false-positive, true-negative, and false-negative values were calculated. [Table 1] shows the comparative data for caries diagnosis between dentist (clinical examination) and the mother (photographic diagnosis). Chi-square test revealed no statistically significant difference between dentist and mother's diagnosis.
Figure 1: Photographs of maxillary (occlusal), mandibular (occlusal), and maxillary and mandibular dentition together. (a) Maxillary dentition occlusal view, (b) mandibular dentition occlusal view, (c) maxillary and mandibular dentition labial view

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Table 1: Difference between the diagnosis made by the examiner and mothers

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Results [Table 2] showed that the sensitivity of mother's diagnosis for their child's dental caries using smartphone-based photographic method was 88.3%, specificity of 98.3%, PPV of 92%, and NPV of 97%. The accuracy of mother's diagnosis for screening dental caries was 96%, and the kappa statistics of 0.87 indicated strong agreement of mother's diagnosis with that of dentist diagnosis.
Table 2: Accuracy and reliability measures

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   Discussion Top

Teledentistry is an approach of screening patients for dental diseases, educating them through talks and videos, and referring the screened patients to nearby hospitals for the treatment. Self-care is the best gift one can gift themselves, and technology can be of help in self-screening. A study [9] of self-screening of oral cancer has been conducted in the past wherein people were educated and made aware about the signs and symptoms of oral cancer which proved to be very beneficial. Based on the results of the present study, the hypothesis has been accepted that mothers have the ability to diagnose dental caries using smartphone photographs.

In the present study, a sensitivity value of 88.3% for mother's diagnosis was reported. A study [7] reported 98% sensitivity in diagnosing dental caries through photographic assessments, where the digital camera was used and dentist himself was the assessor. A sensitivity of 93.1% was reported by Godlevsky et al.,[13] for the detection of early caries in orthodontic patients. While contrasting results have been reported by Estai et al.[14] (sensitivity of 60%–62%) and Estai et al.[6] (sensitivity of 60%–68%). In the present study, a specificity of 98.3% was reported for the mother's diagnosis. The results were similar to the studies reported by Estai et al.,[14] in 2017 and Estai et al., in 2016[6] where sensitivity obtained was 96%–98% and 97%–98%, respectively. Another study [7] reported a low specificity value of 73%.

The PPV and NPV in the present study were 92% and 97%, respectively. Better the predictive values, more reliable would be the test. The PPV reported by the other studies [6],[7],[14] is quite low than the present study. Eatai et al.[6] reported a PPV of 52%–79%, Amável et al.[7] as 80%, and Estai et al.[14] as 57%–66%. The PPV in the present study was comparable with Godlevsky et al.[13] of 91.5% (post correction of images for color quality). The NPV reported in the present study is similar to the study results of Amável et al.[7] reporting NPV of 97%, Estai et al.[14] reporting it as 97%–98%, and Estai et al.[6] reporting it as 97%–98%. A higher NPV as compared to PPV in the present study suggests that it is easy to identify those teeth not having dental caries and report them correctly while identifying those teeth having dental caries is slightly difficult as there can be overestimation because of the presence of occlusal stains or fissure discoloration.

The accuracy of mother's diagnosis in identifying carious teeth was 96% in the present study which was identical with the other studies [6],[14] in the past wherein the photographs using smartphone camera were captured by interns and mid-level dental providers and were assessed by the dentist. The kappa value in the present study was found to be 0.87, suggesting a very good agreement between the dentist and the mothers for diagnosing dental caries among children which was more than other studies.[6],[14] In spite of the fact that the diagnosis was made by the mothers in the present study compared to the dentists in the earlier studies, the inter-rater reliability was found very good, signifying that dental health education to the mothers regarding the dental caries, its appearance, and signs and symptoms might have proved valuable.

Thus, overall it can be believed that high specificity, NPVs, accuracy, and inter-rater reliability with acceptable sensitivity, and PPV are indicative of good diagnostic skills of mothers using the smartphone photographic method.

Interesting findings observed in the present study were children showed less cooperation while undergoing visual examination which may be because of the fear toward the dentist and the instruments used for examining; however, at the same time when examiner started clicking photographs, they showed an excellent comfort level. This may be because children are always fond of smartphone, clicking pictures or getting their pictures clicked, and thus, it may sound to them as an interesting and fun-filled activity over the routine examination with instruments thus making them more cooperative toward the procedure.

The following inference can be drawn from the present study: the annual school oral examination can now be undertaken by the smartphone photographic method replacing the examination with mouth mirror and probe. With advancement in technology, there is inbuilt camera in smartphone with high pixels which will give better quality photographs. Moreover, smartphone is the gadgets which are available with most of the people. Since it is a smartphone, children are more comfortable with it and this act will also inculcate positive attitude toward dentistry. During dental camps [15] in schools or large community, the barrier which may come in the way is maintaining sterilization protocols for the instruments. Maximum times the instruments are sterilized by boiling due to the unavailability of autoclave. Although boiling has been used since decades, it provides only partial sterilization leading to increase in the risk of cross infection.[16] Along with that, the cost of the overall survey tends to increase due to expenditure on the screening instruments. Since smartphone photographic assessment has shown to be comparable with oral examinations, the oral examination at the community level, especially at schools, can be done every 6 monthly and without any hassles. The dentist can take the pictures and there is no botheration of instruments and sterilization protocol, and further, it can be sent to the mother as a dental record of the child's caries status. Further, this study can be extended to train the teachers and health assistants in clicking pictures and to check the effectiveness of caries diagnosis. This can be helpful in areas where there is scarcity of dentist. As photographs captured through smartphone fail to provide clear interproximal pictures, thus underestimating the caries status because of the undiagnosed proximal caries can be one of the drawbacks of the photographic method. Moreover, identifying dental caries at an early stage through photographs to reverse the caries process may be difficult for nondental people. However, with the fast-growing technological advancement, there is a possibility to get a clearer picture so as to identify even the initial carious lesions.

   Conclusion Top

Within the limitations of this study, it can be concluded that the diagnosis made by the dentist and mothers are comparable in detecting dental caries in preschoolchildren. Smartphones can be an inexpensive tool in screening dental caries among the preschoolchildren. With the dental knowledge, the mother can identify the caries in the child's mouth through the smartphone photographic method.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract 2009;27:1-10.  Back to cited text no. 1
Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health 2012;102:1729-34.  Back to cited text no. 2
Hazarika I. Health workforce in India: Assessment of availability, production and distribution. WHO South East Asia J Public Health 2013;2:106-12.  Back to cited text no. 3
Kelly SE, Binkley CJ, Neace WP, Gale BS. Barriers to care-seeking for children's oral health among low-income caregivers. Am J Public Health 2005;95:1345-51.  Back to cited text no. 4
Chandra G, Rao J, Singh K, Gupta K. Teledentistry in India: Time to deliver. J Educ Ethics Dent 12;2:61-4.  Back to cited text no. 5
Estai M, Kanagasingam Y, Huang B, Checker H, Steele L, Kruger E, et al. The efficacy of remote screening for dental caries by mid-level dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44:435-41.  Back to cited text no. 6
Amável R, Cruz-Correia R, Frias-Bulhosa J. Remote diagnosis of children dental problems based on non-invasive photographs – A valid proceeding? Stud Health Technol Inform 2009;150:458-62.  Back to cited text no. 7
Park W, Kim DK, Kim JC, Kim KD, Yoo SK. A portable dental image viewer using a mobile network to provide a tele-dental service. J Telemed Telecare 2009;15:145-9.  Back to cited text no. 8
Elango KJ, Anandkrishnan N, Suresh A, Iyer SK, Ramaiyer SK, Kuriakose MA. Mouth self-examination to improve oral cancer awareness and early detection in a high-risk population. Oral Oncol 2011;47:620-4.  Back to cited text no. 9
Saravanan S, Madivanan I, Subashini B, Felix JW. Prevalence pattern of dental caries in the primary dentition among school children. Indian J Dent Res 2005;16:140-6.  Back to cited text no. 10
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Online Calculator. Available from: http://araw.mede.uic.edu/cgi-bin/testcalc.pl. [Last accessed on 2018 Feb 07].  Back to cited text no. 12
Godlevsky L, Bidnyuk E, Bayazitov N, Kresyun N, Kovalenko A, Lyashenko A, et al. Application of mobile photography with smartphone cameras for monitoring of early caries appearance in the course of orthodontic correction with dental brackets. Appl Med Inform 2013;33:21-6.  Back to cited text no. 13
Estai M, Kanagasingam Y, Huang B, Shiikha J, Kruger E, Bunt S, et al. Comparison of a smartphone-based photographic method with face-to-face caries assessment: A mobile teledentistry model. Telemed J E Health 2017;23:435-40.  Back to cited text no. 14
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Sridhar Rao PN. Sterilization and Disinfection. Available from: https://www.microrao.com/micronotes/sterilization.pdf. [Last accessed on 2018 Dec 28].  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2]

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