Hospitals Association (AHHA), Australia's national peak body for public health care providers

Objective The aim of the present study was to compare the costs of teledentistry and traditional dental screening approaches in Australian school children. Methods A cost-minimisation analysis was performed from the perspective of the oral health system, comparing the cost of dental screening in school children using a traditional visual examination approach with the cost of mid-level dental practitioners (MLDPs), such as dental therapists, screening the same cohort of children remotely using teledentistry. A model was developed to simulate the costs (over a 12-month period) of the two models of dental screening for all school children (2.7million children) aged 5-14 years across all Australian states and territories. The fixed costs and the variable costs, including staff salary, travel and accommodation costs, and cost of supply were calculated. All costs are given in Australian dollars. Results The total estimated cost of the teledentistry model was $50million. The fixed cost of teledentistry was $1million and that of staff salaries (tele-assistants, charters and their supervisors, as well as information technology support was estimated to be $49million. The estimated staff salary saved with the teledentistry model was $56million, and the estimated travel allowance and supply expenses avoided were $16million and $14million respectively; an annual reduction of $85million in total. Conclusions The present study shows that the teledentistry model of dental screening can minimise costs. The estimated savings were due primarily to the low salaries of dental therapists and the avoidance of travel and accommodation costs. Such savings could be redistributed to improve infrastructure and oral health services in rural or other underserved areas. What is known about the topic? Caries is a preventable disease, which, if it remains untreated, can cause significant morbidity requiring costly treatment. Regular dental screening and oral health education have the great potential to improve oral health and save significant resources. The use of role substitution, such as using MLDPs to provide oral care has been well acknowledged worldwide because of their ability to provide safe and effective care. The teledentistry approach for dental screening offers a comparable diagnostic performance to the traditional visual approach. What does this paper add? The results of the present study suggest that teledentistry is a practical and economically viable approach for mass dental screening not only for isolated communities, but also for underserved urban communities. The costs of the teledentistry model were substantially lower than the costs associated with a conventional, face-to-face approach to dental screening in both remote and urban areas. The primary driver of net savings is the low salary of MLDPs and avoidance of travel and overnight accommodation by MLDPs. What are the implications for practitioners? The use of lower-cost MLDPs and a teledentistry model for dental screening has the potential to save significant economic and human resources that can be redirected to improve infrastructure and oral care services in underserved regions. In the absence of evidence of the economic usefulness of teledentistry, studies such as the present one can increase the acceptance of this technology among dental care providers and guide future decisions on whether or not to implement teledentistry services.

OBJECTIVE:To estimate the scale of resource transfer that could be achieved by screening low-risk schoolchildren using teledentistry rather than using traditional visual dental examination.METHODS:This study was based on a previous cost-minimisation study that compared the costs of two dental-screening approaches (visual and teledentistry). The data for the population of children 5-14 years of age was obtained from the Australian Bureau of Statistics and was divided across Australia according to statistical local area (SA2). The cost models (for teledentistry and visual screening) for each SA2 relative to the state, Remoteness Area (RA) and Socio-Economic Index for Area (SEIFA) indexes were estimated. The geographical information system was used to superimpose modelled cost data on the geographical map to provide a visual presentation of the data. Resource transfer scenarios, based on risk minimisation, were then developed and analysed.RESULTS:This study demonstrated a suboptimal allocation of dental-care resources, such that children living in high socio-economic areas (major cities) with low disease burdens consuming half of the estimated resources of a universal visual dental screening system. The findings suggest that utilising teledentistry screening for low-risk children has the potential to free up $40 million per annum. Such resources can be reallocated to increase care access and improve the quality of dental services for vulnerable children.CONCLUSION:To reduce inequalities in dental health within a community, scarce health-care resources should be targeted at the population at most risk. These findings can be used to inform policymakers, guide the appropriate distribution of scarce resources and target dental services to benefit high-need children.

Objective This review is designed to inform future decisions about the benefits of integrating teledentistry into routine health services, by presenting an overview of the evidence for the effectiveness and economic impact of teledentistry. Methods Two reviewers searched PubMed, EMBASE and CINAHL databases through November 2016 to identify published peer-reviewed studies in English. Teledentistry studies were included if they were; (a) controlled (randomised or non-randomised) assessment studies; and (b) compared outcomes of a teledentistry intervention in terms of clinical or economic evaluation with the outcomes of traditional clinical alternatives. The quality of the studies was evaluated using a quality appraisal tool that considered study performance and design. Results This review identified 385 publications, of which 217 full-text articles were retrieved for further inspection. Of these, only 11 articles met the inclusion criteria. Nine of the included articles showed some clinical outcomes; the other two were primarily economic analyses. The balance of these studies assesed the efficacy of teledentistry interventions rather than their effectiveness. Four studies (36%) achieved higher quality scores and have greater potential to influence health-care decision-making. To date, the most convincing published evidence regarding the efficacy of teledentistry was provided by studies on paediatric dentistry, orthodontics and oral medicine. The economic analysis referred only to cost-minimisation, suggesting that the use of teleconsultation in dentistry can be cost-saving when compared to a conventional consultation. However, high-quality economic studies on teledentistry are rare. Conclusion There is emerging evidence supporting the efficacy of teledentistry. However, there is not yet enough conclusive evidence, particularly for its effectiveness, cost-effectiveness and long-term use, to make evidence-based policy decisions on teledentistry.

The global improvements in oral health over recent decades, particularly in children, have led many to believe that most dental problems are solved. However, dental caries remains the single most prevalent chronic disease of childhood and causes serious health consequences requiring costly treatment. Nearly 50% of Australian children suffer from caries by the age of 6 years.1 The problem is particularly severe amongst socially disadvantaged children, causing a significant burden, not only on individuals but also on the government. Caries is regarded as the second most costly diet-related disease, ahead of cardiovascular disease and diabetes.2 Between 2005 and 2013, the national expenditure on oral care escalated from A$6 to A$9 billion.3 Dental services are not only unevenly available across Australia but there are inequalities in utilisation of dental services. Children with the greatest needs who already have poorer oral health, have limited or no access to care; while children with the least needs, have easy access to care and consume the most expensive resources. As a result, much dental disease amongst socially disadvantaged children goes without treatment, widening the gap between the level of their oral health and the rest of the population. The reasons for oral health inequalities are varied but mainly pertains to the inequity in dental care access, often due to socioeconomic gradients and the shortages in the dental workforce.4 Although school dental therapists have been responsible for providing most of the dental services through the School Dental Service (SDS), this programme rarely delivers a sustainable dental care for all children, with nearly half of the school children cared for in the SDS suffering from poor oral health.5 In recent years, the SDS has faced a reduction in manpower participation, and services remain largely clustered in urban regions.5, 6 The decreased retention and recruitment of school dental therapists have been attributed to their preferring to practise in the private sector.7 Healthy behaviours established in early life are often carried into adulthood.8 Therefore, improving oral health in childhood is fundamental for reducing dental caries, early tooth loss and other oral diseases in adulthood. Caries appears mainly during childhood and adolescence, its impact can be reduced through shifting the emphasis of dental care from the provision of treatment towards effective prevention of dental diseases. To achieve this, a range of preventive measures can be adopted such as oral health promotion, systemic and topical fluoridation, and sealants.4 However, such strategies can be unsuccessful if not targeted at high-risk children or those with high needs. Dental screening in asymptomatic school children can provide a way to identify high-risk groups and offer a valuable strategy for more effective disease prevention and control. There are many methods for dental screening, although tactile or visual inspection remains the most common method. However, this technique has a limitation as it is inappropriate in a large-scale epidemiological setting. The cost of visual inspection can be excessively high due to the expense of travelling and the high salaries of trained personnel. One of the practical solutions to address the inequality in oral health and improving oral health is the use of mobile applications in screening for dental diseases in asymptomatic school children. Mobile health or mHealth refers to the use of mobile devices to facilitate data and information exchange between patients and health care providers. mHealth applications have become increasingly popular due to improved global cellular infrastructure and the increased affordability of mobile devices. Most mHealth applications rely on mobile devices and its widespread use (the majority of the world's population now use mobile devices). mHealth is an attractive technology due to mobile connectivity, digital photography capabilities and the computational power of modern mobile phones which allow their users to perform multiple tasks such as processing, storage and transmission of data as well as access to low-cost, secure ‘cloud’ storage. As mobile devices are constantly carried and can be used at any time, they can be utilised as point-of-care devices to improve the delivery of patient-centred care. Their use in disease surveillance, particularly in the screening for skin malignancies9 and hearing impairment,10 has proven to be effective. However, the body of literature on mHealth applications in dentistry is still limited.11 Until recently, the use of mobile devices in dentistry was not well received because of the poor quality of their cameras, limited storage space and data transfer failure. Their recent introduction into dental research has shown an acceptable screening performance in comparison with visual inspection, particularly in the screening for dental caries12-15 and oral cancer or precancerous lesions.16, 17 The use of a mobile camera in dental photography can be useful for recording a baseline of oral health status preoperatively, which can be used to confirm the diagnosis and preparing an appropriate treatment plan. Also, it can be helpful to prioritise patients when referring to consultants and avoid delay in treatment, particularly for urgent or complicated cases. Improving the public's oral health is challenging, with unequal distribution of the dental workforce and scarcity of resources making the transition to the prevention of diseases difficult. Dental screening is a step towards the implementation of long-term preventive measures and effective control of common dental diseases like dental caries. The implementation of a large-scale and efficacious epidemiological oral screening requires an economical and effective screening tool that is used by trained non-health professionals (e.g. teachers or parents), with a practitioner (dentist or dental therapist) evaluating dental photographs and preparing a treatment plan at a distance.18 The use of mHealth applications to screen for dental diseases in children is a worthwhile initiative to control dental diseases by identifying screened positive children and providing them with a quick pathway to receive appropriate treatment. Children who are considered to be at low risk do not need additional management other than to receive preventive care. This strategy can help in the allocation of scarce resources, directing specific dental care towards a population group who most need it and contribute to reducing inequalities in oral health.

OBJECTIVES:This study sought to evaluate the efficacy of a mobile teledentistry approach using a smartphone camera for remote screening of dental caries.MATERIALS AND METHODS:An image acquisition Android App was created to facilitate the acquisition and transmission of dental images to a store-and-forward based telemedicine server. One hundred participants who were attending routine checkups at dental clinics were enrolled in 2014. Following a face-to-face oral screening by a screener (dentist), images of patients' teeth were obtained using a smartphone camera. These images, along with patient information, were then transmitted from the Android App to the server through the Internet for later independent assessment by two charters (off-site dentists). The assessments of these charters were then compared to the benchmark face-to-face caries assessment.RESULTS:Sensitivity values for the photographic method when compared to the benchmark face-to-face caries assessment were moderate, and ranged from 60% to 63%. Weighted kappa (K) as a measure of intragrader agreement for the photographic assessment was estimated as almost perfect (K = 0.84). The intergrader agreement for the photographic method compared to the face-to-face caries assessment ranged from moderate to substantial (K = 0.54-0.66).CONCLUSIONS:Despite some limitations, the mobile teledentistry approach has shown the potential to detect occlusal caries from photographs taken by a smartphone camera with an acceptable diagnostic performance compared to traditional face-to-face screening. This study suggests that telemedicine and cellular phone technology can be combined to create an inexpensive and reliable screening tool.

Objective This study aimed to evaluate users’ acceptance of a teledentistry model utilizing a smartphone camera used for dental caries screening and to identify a number of areas for improvement of the system. Methods A store-and-forward telemedicine platform “Remote-I” was developed to assist in the screening of oral diseases using an image acquisition Android app operated by 17 teledental assistants. A total of 485 images (five images per case) were directly transmitted from the Android app to the server. A panel of five dental practitioners (graders) assessed the images and reported their diagnosis. A user acceptance survey was sent to the graders and smartphone users following completion of the screening program. Results Of the 22 surveys sent out, 20 (91%) were completed. Generally, users showed optimism towards the use of the teledentistry system, and strongly positively assessed items on content and service quality. The majority of graders took less than 15 min to read the images while phone users took 5–10 min to complete the dental photography using the Android app. This study identified a number of factors that are essential for improving the current system, such as optimization of smartphone camera features, the format of the server, and the orientation of images and using oral retractors during photography. Conclusions Users appear to be generally satisfied with the proposed teledentistry model. However, they have specific concerns to address, many of which could be resolved through more effective training, coordination between sites and upgrading the current system.

OBJECTIVE:This study sought to systematically review the literature for research evidence for the diagnostic accuracy of teledentistry in the detection of dental caries. METHODS:Two reviewers searched PubMed, EMBASE, and Scopus databases through January 2016 for comparative studies that examined the diagnostic accuracy of teledentistry for detecting caries compared with nontelemedicine alternatives. Retrieved studies were screened for inclusion criteria and were evaluated for methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) checklist. RESULTS:Of 287 citations identified, 10 met the preset inclusion criteria. Sensitivity and specificity were the most common measures of diagnostic accuracy used in 10 studies. Despite very limited published evidence on the diagnostic accuracy of teledentistry, the reviewed teledentistry studies showed comparable diagnostic performance compared with nontelemedicine alternatives. The average methodological quality of the selected articles is low, since none of the selected studies satisfied all 4 QUADAS-2 domains. Only 6 articles were scored as having a low risk of bias in 3 of 4 of QUADAS-2 domains. All the selected studies had low concerns regarding applicability. The main shortcoming was that in most of the selected studies, the methodology, in particular patient selection and index tests, was insufficiently described. CONCLUSIONS:Teledentistry has an acceptable diagnostic performance in the detection of dental caries. However, due to the heterogeneity of the reviewed studies, the generalization of results may be difficult. Further well-designed research to investigate the effectiveness of the teledentistry approach to caries detection is needed to determine the capability of this technology in epidemiologic oral surveys.

Computational methods originally developed for analysis in engineering have been applied to the analysis of biological materials for many years. One particular application of these engineering tools is the brain, allowing researchers to predict the behaviour of brain tissue in various traumatic, surgical and medical scenarios. Typically two different approaches have been used to model deformation of brain tissue: single-phase models which treat the brain as a viscoelastic material, and biphasic models which treat the brain as a porous deformable medium through which liquid can move. In order to model the brain as a biphasic continuum, the hydraulic conductivity of the solid phase is required; there are many theoretical values for this conductivity in the literature, with variations of up to three orders of magnitude. We carried out a series of simple experiments using lamb and sheep brain tissue to establish the rate at which cerebrospinal fluid moves through the brain parenchyma. Mindful of possible variations in hydraulic conductivity with tissue deformation, our intention was to carry out our experiments on brain tissue subjected to minimal deformation. This has enabled us to compare the rate of flow with values predicted by some of the theoretical values of hydraulic conductivity from the literature. Our results indicate that the hydraulic conductivity of the brain parenchyma is consistent with the lowest theoretical published values. These extremely low hydraulic conductivities lead to such low rates of CSF flow through the brain tissue that in effect the material behaves as a single-phase deformable solid.

With the availability of oral care services very unevenly distributed in rural or remote areas, underserved people seek oral care from non-dental care providers. Against this backdrop, and coupled with the decreasing cost of and innovations in technology, there is a growing interest in the adoption of telemedicine services. Regardless of the lack of good-quality evidence supporting the cost-effectiveness of telemedicine, evidence already indicates that telemedicine, even with extra costs, helps in reducing the inequalities in the provision of primary health care. Telemedicine has the potential to overcome geographical barriers and contribute to closing the rural-urban healthcare gap in Australia and many other regions. Although research examining different teledentistry applications has found that this technology can be successfully integrated into different settings, there is little active teledentistry practice in Australia. The integration of telemedicine into the mainstream oral health system is a complex and collaborative process in which numerous factors at individual, infrastructure and organisational levels are involved. Addressing the barriers that delay the implementation of a teledentistry service can provide valuable insights into its lack of acceptance and establish an evidence base that can help to inform future decisions about the benefits of teledentistry.

In this report we review the range of teaching resources and strategies used in anatomy education with the aim of coming up with suggestions about the best teaching practices in this area. There is much debate about suitable methods of delivering anatomical knowledge. Competent clinicians, particularly surgeons, need a deep understanding of anatomy for safe clinical procedures. However, because students have had very limited exposure to anatomy during clinical training, there is a concern that medical students are ill-prepared in anatomy when entering clerkships and residency programs. Therefore, developing effective modalities for teaching anatomy is essential to safe medical practice. Cadaver-based instruction has survived as the main instructional tool for hundreds of years, however, there are differing views on whether full cadaver dissection is still appropriate for a modern undergraduate training. The limitations on curricular time, trained anatomy faculty and resources for gross anatomy courses in integrated or/and system-based curricula, have led many medical schools to abandon costly and time-consuming dissection-based instruction in favour of alternative methods of instruction including prosection, medical imaging, living anatomy and multimedia resources. To date, no single teaching tool has been found to meet curriculum requirements. The best way to teach modern anatomy is by combining multiple pedagogical resources to complement one another, students appear to learn more effectively when multimodal and system-based approaches are integrated. Our review suggests that certain professions would have more benefit from certain educational methods or strategies than others. Full body dissection would be best reserved for medical students, especially those with surgical career intentions, while teaching based on prosections and plastination is more suitable for dental, pharmacy and allied health science students. There is a need to direct future research towards evaluation of the suitability of the new teaching methodologies in new curricula and student perceptions of integrated and multimodal teaching paradigms, and the ability of these to satisfy learning outcomes.

We are developing a three-dimensional (3D) model of the rat spinal cord to act as a reliable tool for investigating mechanisms of spinal injury. Segmentation and meshing, by which the spinal geometry is extracted into a model, requires both considerably clear boundaries and high-contrast representation of the cord components: white matter, grey matter, meninges, CSF and IVD. Unfortunately, despite the advancement of MRI technology, obtaining high-resolution and high-contrast spinal cord of the rat is not an easy task; tedious protocols set up are required. This work comparedtwoprotocols that are commonly used for in-vivo MRI acquisitions; FLASH (T1 weighted) and TurboRare(T2 weighted). The software packages MicroDICOM and Mimics were used to assess the outcome of each protocol. As further comparison, we also examined ex-vivo datasets obtaining with MSME (T2 and proton density weighted) acquisition. The assessment was made based on the clarity of canny edgecontrast detection and the amount of unintended objects adjacent to the spinal cord components on the 3D model. We found that compared to TurboRare (T2 weighted), FLASH (T1 weighted) visually produced higher contrast between white and grey matter. This visual assessment was confirmed by the canny edge boundary detection on MicroDICOM. On Mimics, this difference was not detectable. Although the amount of unintended structures of the 3D modelof FLASH (T1 weighted) acquisitions less than that of the TurboRare (T2 weighted), it was more likely due to the signal uniformity rather than the effect of acquisition selection. Additionally, since this work only involved 3 datasets, whereby the statistical validation is not sufficient, we could not suggesta conclusive finding. However, this work is important as the basis further MRI protocol comparison studies.

It is possible to improve neuronavigation during image-guided surgery by warping the high-quality preoperative brain images so that they correspond with the current intraoperative configuration of the brain. In this paper, the accuracy of registration results obtained using comprehensive biomechanical models is compared with the accuracy of rigid registration, the technology currently available to patients. This comparison allows investigation into whether biomechanical modeling provides good-quality image data for neuronavigation for a larger proportion of patients than rigid registration. Preoperative images for 33 neurosurgery cases were warped onto their respective intraoperative configurations using both the biomechanics-based method and rigid registration. The Hausdorff distance based evaluation process, which measures the difference between images, was used to quantify the performance of both registration methods. A statistical test for difference in proportions was conducted to evaluate the null hypothesis that the proportion of patients for whom improved neuronavigation can be achieved is the same for rigid and biomechanics-based registration. The null hypothesis was confidently rejected (p < 10(-4)). Even the modified hypothesis that fewer than 25% of patients would benefit from the use of biomechanics-based registration was rejected at a significance level of 5% (p = 0.02). The biomechanics-based method proved particularly effective in cases demonstrating large craniotomy-induced brain deformations. The outcome of this analysis suggests that nonlinear biomechanics-based methods are beneficial to a large proportion of patients and can be considered for use in the operating theater as a possible means of improving neuronavigation and surgical outcomes.

Knowledge of the mechanical properties of the brain-skull interface is important for surgery simulation and injury biomechanics. These properties are known only to a limited extent. In this study we conducted in situ indentation of the sheep brain, and proposed to derive the macroscopic mechanical properties of the brain-skull interface from the results of these experiments. To the best of our knowledge, this is the first ever analysis of this kind. When conducting in situ indentation of the brain, the reaction force on the indentor was measured. After the indentation, a cylindrical sample of the brain tissue was extracted and subjected to uniaxial compression test. A model of the brain indentation experiment was built in the Finite Element (FE) solver ABAQUS™. In the model, the mechanical properties of the brain tissue were assigned as obtained from the uniaxial compression test and the brain-skull interface was modeled as linear springs. The interface stiffness (defined as sum of stiffnesses of the springs divided by the interface area) was varied to obtain good agreement between the calculated and experimentally measured indentor force-displacement relationship. Such agreement was found to occur for the brain-skull interface stiffness of 11.45 Nmm⁻¹/mm². This allowed identification of the overall mechanical properties of the brain-skull interface.

The induction of fibroblast apoptosis and their clearance by phagocytes is essential for normal wound healing and prevention of scarring. However, little is known about the clearance of apoptotic fibroblasts and whether apoptotic cells are active participants in the recruitment and activation of phagocytes. In this study, we provide the first evidence that apoptotic fibroblasts actively release increased amounts of thrombospondin (TSP1) to actively recruit macrophages. Expression of TSP1 and its receptor CD36 was increased on the surface of apoptotic fibroblasts. By chemical cross-linking and immunoprecipitation we show that TSP1 and CD36 were directly associated. This was confirmed by confocal microscopy. Blockade of either CD36 or TSP1 on apoptotic fibroblasts inhibited phagocytosis. Blockade of alpha v beta 3 integrins as well as CD36 and TSP1 on macrophages inhibited phagocytosis. In contrast, phosphatidylserine or lectins were not involved. These findings suggest that apoptotic fibroblasts release TSP1 as a signal to recruit macrophages while the up-regulated expression of the CD36/TSP1 complex on their cell surface may form a ligand bridging the fibroblast to a complex consisting of alpha v beta 3/CD36/TSP1 on macrophages. These results establish fundamental mechanisms for the clearance of apoptotic fibroblasts and may provide insights into the processes involved in normal wound repair.