Comparison of teledentistry and on-site clinical diagnosis using the International Caries Detection and Assessment System (ICDAS) in Rawalpindi and Islamabad: a validation study

Volume 2
Pages 23-29
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Dental caries significantly impact global health, particularly in Pakistan, where the prevalence is notably high. This study assessed the diagnostic accuracy of mobile teledentistry in Islamabad and Rawalpindi by employing the International Caries Detection and Assessment System (ICDAS) as a benchmark. This cross-sectional validation study was conducted from July to September 2022 in nine private dental clinics involving 460 participants proficient in basic Android smartphone functions. The diagnostic procedure comprised initial in-person evaluations by dentists, subsequent remote assessments using images captured by smartphones based on verbal instructions, and validations by a third independent dentist. Statistical analyses were performed using sensitivity, specificity, Matthew’s correlation coefficient, and receiver operating characteristic (ROC) curves. Teledentistry achieved a specificity of 89% and a sensitivity of 70%. The positive and negative predictive values were 74.6% and 86%, respectively. The ROC curve analysis, with an area under the curve greater than 0.7, confirmed the high diagnostic efficacy of the method. The Cohen’s kappa statistic reached 0.814, demonstrating substantial interrater reliability, while the diagnostic odds ratio was 18, indicating strong discriminative power. This study confirmed that teledentistry, enabled by the use of smartphone cameras, serves as a reliable method for detecting dental caries, with efficacy comparable to that of conventional clinical examination methods. It significantly extends dental care accessibility, particularly in geographically remote or economically underserved regions, effectively mitigating the logistical challenges associated with traditional dental visits. The findings support the broader implementation of teledentistry, highlighting its potential to enhance mass screening efforts, improve oral health outcomes, and alleviate pressures on healthcare systems across diverse demographic landscapes.


Teledentistry; Telecommunications; Delivery of healthcare; Dental software; Dental caries/diagnosis

1. Introduction

Since the dawn of humanity, the need for dental treatment has become evident as oral diseases continue to pose a significant global health challenge [1]. It is evident from historical analyses that dental caries, a predominant oral condition, has afflicted humans since antiquity, as evidenced by carious teeth found in ancient skeletal remains [2,3]. According to the Global Burden of Disease Study 2017, oral diseases are considered among the most prevalent noncommunicable diseases worldwide, affecting approximately 3.5 billion people. Among these, approximately 2.3 billion people suffer from untreated caries in their permanent teeth, while approximately 532 million children experience untreated caries in their deciduous (baby) teeth [4,5,6].

Oral health is an important indicator of overall health and well-being. However, in many regions, it is regarded more as a personal responsibility than a collective societal concern [5]. Inadequate oral hygiene not only impacts eating and speaking abilities but is also associated with critical noncommunicable diseases such as respiratory disorders, cancers, and cardiovascular conditions [5,7,8]. The worldwide impact of oral diseases is considerable, with approximately 15 million disability-adjusted life years reported as lost in 2017, alongside notable economic burdens costing approximately 298 billion dollars in treatment expenses and 144 billion dollars due to productivity losses [9].

In Pakistan, the burden of dental caries is particularly high, with national studies indicating a prevalence of approximately 56.62%, reflecting significant regional variations [10]. Moreover, in Bhara Kahu, Islamabad—where this study is based—the prevalence among preschool children has been reported to be 49% [11]. This high incidence underscores the urgent public health challenge posed by oral diseases in the country and highlights the critical need for innovative solutions to improve oral healthcare delivery [12].

The introduction of teledentistry has emerged as a significant innovation in dental care, especially during the COVID-19 pandemic, when traditional in-person consultations were frequently disrupted, demonstrating its potential to maintain continuity of care [13,14,15]. However, despite its promise, the body of research on teledentistry is still limited, with a particular lack of rigorous, comparative studies that examine its efficacy on an individual basis [13]. Additionally, there is a notable gap in the literature regarding the reliability of teledentistry outcomes when services are rendered by varying dentists rather than a consistent practitioner [16].

This study aimed to evaluate the effectiveness of mobile teledentistry in Islamabad and Rawalpindi, specifically focusing on its specificity, sensitivity, and predictive value when utilized by individuals without specialized photographic skills. The objective of this study was to determine the diagnostic accuracy of mobile teledentistry using the International Caries Detection and Assessment System (ICDAS) as a reference, assessing its potential to deliver accurate diagnoses in a nonclinical setting.

2. Methods

This cross-sectional validation study was conducted from July to September 2022 across nine private dental clinics in Rawalpindi and Islamabad, which were selected for their comprehensive facilities necessary to support the research. Ethical approval was obtained from the Ethical Review Committee of the Armed Forces Post Graduate Medical Institute (AFPGMI), Rawalpindi (No. 249-AAA-ERC-AFPGMI).

To enhance the study’s power, the sample size was increased from 156 to 480, based on initial calculations from the Raosoft sample size calculator targeting a sensitivity of 88.5%, a margin of error of 5%, and a 95% confidence interval, referencing findings from a recent 2022 study [17,18]. The study employed a nonprobability consecutive sampling technique.

The participants included were individuals of both genders who had basic knowledge of Android smartphone camera functions. The study excluded individuals who were unwilling to provide consent or who did not meet specific health criteria necessary for accurate dental assessments, such as those with preexisting conditions that could interfere with dental evaluations. Written informed consent was obtained from all participants prior to data collection.

The data were collected using a structured questionnaire focused on dental health and the applicability of teledentistry. The diagnostic process comprised three phases: an initial in-person evaluation of dental caries by a dentist using ICDAS [19], followed by a remote assessment by another dentist using images taken based on verbal instructions, and a validation of these diagnoses by a third independent dentist.

Figure 1. A demonstration of an ideal set of pictures for the diagnosis of dental caries for android users.

Data analysis was conducted using SPSS version 21.00, and the results are presented as frequencies and percentages. The study computed measures such as sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the photographic diagnosis method. The effectiveness of this method was evaluated using a receiver operating characteristic (ROC) curve by plotting sensitivity against specificity. Interrater reliability was assessed using Cohen’s kappa statistic, and Youden’s index was calculated.

3. Results

A total of 460 patients were examined. The specificity of teledentistry in reference to clinical check scoring of the ICDAS was 89%. The sensitivity was 70%, whereas the negative predictive value and positive predictive value were 86% and 74.6%, respectively (Table 1).

Table 1. Performance of teledentistry and physical examination in dental caries detection using ICDAS.
Description Physical Examination Total
Caries Positive Caries Negative
Teledentistry Caries Positive

True Positive (TP)

False Positive (FP)


Caries Negative

False Negative (FN)

True Negative (FN)

Total 149 321 460

The evaluation of teledentistry’s diagnostic accuracy revealed a sensitivity of 69.79%, indicating its ability to correctly identify the presence of dental caries in patients. The specificity was determined to be 89%, demonstrating its effectiveness in correctly ruling out patients without the disease. Moreover, the Youden’s index, a measure of the overall effectiveness of the diagnostic test, was calculated at 58.79.

Further in-depth analysis revealed that the MCC was 0.595, reflecting a moderate quality of the diagnostic process. The Cohen’s kappa coefficient reached 0.814, indicating substantial interrater agreement and consistency across different evaluators. The diagnostic odds ratio was 18, indicating the strong discriminative power of the test. Moreover, the Balanced Accuracy of the test was 73.40%, showing its accuracy in identifying both conditions—diseased and nondiseased.

The area under the ROC curve for teledentistry was greater than 0.7, highlighting its ability to discriminate between patients with and without dental caries, thus confirming its strong diagnostic accuracy.

Figure 2. ROC curve illustrating the sensitivity and specificity of teledentistry with an area under the ROC curve of 0.7

4. Discussion

Teledentistry has been a valuable tool in Pakistan for a long time, and its effectiveness during the COVID-19 pandemic has been demonstrated [20,21,22]. Despite its extensive use, comprehensive validity research within Pakistan remains scarce. A systematic review revealed wide variability in the reported validity of teledentistry, with a sensitivity ranging from 25–100% and a specificity ranging from 68–100%, indicating diverse diagnostic accuracies across different settings [23].

Studies in other regions also reflect this variability. For instance, a study in rural India reported high sensitivity using video-based teledentistry [24], while a randomized controlled trial noted similarly high sensitivity [25]. High sensitivity was also observed in studies employing ICDAS for diagnosis, particularly in controlled, in vitro settings using high-quality cameras [26,27]. Conversely, studies that utilized less specialized photographic methods generally reported lower sensitivity, similar to findings in our context where photography was conducted by patients’ attendants based on verbal instructions.

A study conducted by Kopycka-Kedzierawski suggested that intraoral cameras could be a cost-effective alternative to traditional visual examinations, especially for underserved populations, reinforcing the potential of teledentistry as a scalable solution for broad application [28]. Other studies have shown teledentistry to be reliable, supporting its continued use and development [29,30,31].

This study benefits from a real-world application in urban centers, integrating the latest mobile technology, which makes it highly relevant to today’s digital health landscape. The use of the ICDAS provides a standardized diagnostic criterion, enhancing the study’s reliability. However, the study is limited by its focus on urban populations, potentially limiting the applicability of the results to rural or less technologically equipped areas. The variability in image quality, which is dependent on nonspecialist photography, could also impact diagnostic accuracy. Additionally, while the study provides insights into the feasibility of teledentistry, geographic and technological constraints may affect the generalizability of the findings.

5. Conclusions

This study confirmed that teledentistry, facilitated by the use of smartphone cameras, serves as a reliable method for detecting dental caries with efficacy comparable to that of conventional clinical examination methods. Moreover, the delegation of nondentist personnel for image acquisition significantly extends dental care accessibility, particularly in geographically remote or economically underserved regions. The use of smartphones in this diagnostic context effectively mitigates the logistical challenges associated with traditional dental visits. It reduces both physical and psychological discomfort for patients. The findings advocate for the expanded implementation of teledentistry, underscoring its potential to enhance mass screening efforts, improve oral health outcomes, and alleviate pressures on healthcare systems across diverse demographic landscapes.

Author contributions

Conceptualization, SA, HM, MZR, and HA; methodology, SA, HM, MZR, HA QUA, MR, and HM; software, SBSG, QUA, and HM; validation, HA; formal analysis, SBSG, QUA, and HM; investigation, SA, HM, MZR, and MR; resources, HA; data curation, SBSG, QUA, and HM; writing—original draft preparation, SA, HM, MZR, SBSG, QUA, MR, and HM; writing—review and editing, HA; visualization, MZR, SBSG, QUA, and HM; supervision, HA; project administration, HA. All authors have read and agreed to the published version of the manuscript.

Publication history

Received Revised Accepted Published
18 August 2023 23 September 2023 27 September 2023 04 October 2023


This research received no specific grant from public, commercial, or not-for-profit funding agencies.

Ethics Statement

Ethical approval was obtained from the Ethical Review Committee of the Armed Forces Post Graduate Medical Institute (AFPGMI), Rawalpindi (No. 249-AAA-ERC-AFPGMI).

Consent to participate

Written informed consent was obtained from all participants prior to data collection.

Data availability

The data supporting this study’s findings are available from the corresponding author, Hassan, upon reasonable request.



Conflicts of interest

The authors declare no conflicts of interest.


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