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A new term e-dentistry or tele-dentistry is getting popularity these days in e-health which uses electronic processes and communication for the transfer of dental health resources and health-care by electronic means. Practice of e-dentistry is not adequate in Pakistan. The main objective of the study was to assess Knowledge and Attitude of Dentists towards tele-Dentistry in Pakistan.

The data were collected through the self designed questionnaire. Study sample (n=155) included 92 males and 63 females. Mean age of male respondents was 29.575.3 years and the mean age of female respondents was 29.25.3 years.

According to the results of the study 37.4% respondents reported "yes" about knowledge about e-health. 23.9% reported "yes" about the knowledge of Open Dental or Free Dental software. 13.5% respondents had knowledge about the databases used now a days. 72.3% didn't mention any use of e-health. 30.3% respondents had attended seminar on e-health. No respondent had practiced tele-dental health. 38.1% respondents agreed for practicability of e-health. 39.35% respondents reported that tele-dentistry can be practiced in Pakistan. 21% respondents recommended some areas where tele-dentistry can be applied.

There are still significant gaps in the facts between where e-health is used and where its use is supported by high-quality evidence. Tele-dentistry has a potential to benefit the Pakistan's healthcare system in terms of preventive care and disease treatment.

Key Words: Communication, e-dental health, Healthcare, Tele-dentistry Knowledge, Practice.


An innovation been made in the field of health for saving lives in the remote regions of any country. This innovation is the e-health. e-Health is the use of information and communication technologies (ICT) for health care. It is recognized as one of the most rapidly growing areas in health today. Being member of WHO, Pakistan had to develop strategy and plan for e-health but it is still considered a new concept here and situation of telemedicine and e-health policy is very alarming here in contrast of 55% of the member states of WHO.1

E-health is broadly used in many fields of health like Electronic health records Electronic medical records,2-4 Computerized Physician Order Entry (CPOE),5,6 e-Prescribing,7-9,2) clinical decision support,10 telemedicine,11 consumer health informatics,12 health knowledge management, Virtual healthcare teams, mHealth or m-Health,13 medical research using Grids and Healthcare Information Systems.14

Public health monitoring has become easy due to e-health. Educating health workforce, conducting research and treating patients are some examples of e-health to transfer health resources and health care by using Information and Communication Technology. IT, e-business and e-commerce play an important role to improve the public health services.15

There are many branches of health covered by e-health like e-medicine, e-pharmacy, e-health record keeping (Personally Controlled Electronic Health Record).16 E-health record provides a health summery to avoid mix-ups of the data of patients. A new term in dentistry is prevailing data by day which is called as Personally Controlled Electronic Health Record (PCEHR).17 According to Australian Dental Association it is not an electronic document but a "health record" and it should be called as "health summary" to avoid mix-ups.18

Electronic health records were first started in 1960s. It was mostly used by healthcare insurance agencies and companies. In 1990s American Dental Association in collaboration with many others introduced an electronic oral health record of the patients and formed a committee called Standards Committee for Dental Informatics having mission to improve patient care and oral health by using Information Communication Technology. Revolution has occurred in the use of electronic records as well. As compared to 18% use of electronic health record (EHR) there is an increase of 78% of use of electronic health record by physicians according to a report of America.19

In May 2005 an eHealth strategy for WHO was developed by the Fifty-eighth World Health Assembly by adopting Resolution WHA58.28. In this resolution the member countries were urged to develop a plan for e-health services in their countries.4 In Pakistan some e-health programs are running but no dental programme is in process. So e-health is an important tool which can help the dentists to maintain dental records of the patients. e-health encompasses all the principles and policies their implementations and proves to be productive for the organization and the dentist.

There are different softwares through which e-dental services can be applied; open dental is one of them. Open Dental, or Free Dental, is a licensed Online Management Software. It is compatible with Microsoft because it is written in the C# programming language. It can be used 1) in making online appointments,20 2) supporting complete patient records,21 3) scheduling the recalls of patients and controlling the account of the patients like payment plans, email, referrals, lab cases,22 4) treatment plan, charts, dental image making.22

Open dental is also used to create and send e-claims or paper claims, Billing automation, Audio and Visual office intercom, Critical data backup, Flexible user-defined queries and reports, Track employees' hours and breaks, Supporting daily, weekly and monthly task lists, Built-in accounting module, Secure remote access.23

In Pakistan a few e-health companies are working online. Dental e-health is a new concept in Pakistan and it needs to be explored by the dentists. Therefore the objectives of present study were to determine the knowledge of dentists about tele-dentistry, to determine dentist's perceived obstacles and its practicability in improving dental health in remote areas and to determine dentist's attitudes toward tele-dentistry.


It was a cross-sectional descriptive study design using purposive sampling. Targeted population was dentists of Islamabad (n=155). Dentists from different hospitals were approached for the purpose of data collection and one to one approach was used to fill questionnaire. 170 dentists working in different hospitals and dental clinics of Islamabad were contacted.

15 dentists refused to participate in the study and 155 agreed.

A self structured questionnaire was developed for pilot study and administered for pretesting to a sample of 32 dentists to gain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. A final questionnaire was designed consisting of structured and non structured questions. The questionnaire was divided into three sections. First section consisted of demographic characters of the respondents, second consisted of knowledge about the e-dental health and third was to have views and opinions of dentists about practicability of e-dental health in Pakistan. Response rate was 91.17%. Coding of structured and non-structured questionnaires was done and data were analyzed by using SPSS version 20. Chi-square test was performed for finding out p-value of different variables used in the study.


Out of 155 dentists 59.4% participants were males and 40.6% were females. Mean age of male participants was 29.57 years with the standard deviation of 5.3 SD and the mean age of female participants was 29.2 years with a standard deviation of 5.3SD. 74.8% of the participants had BDS qualification and 25.2% had done specialization. All participants reported that they had not practiced e-dental health anywhere in Pakistan. An average of experience was found to be 6.01 years7.75SD. Details of results can be seen in Fig 1-2 and in Tables 1-4.


Sr.###Variables###Yes (%)###No (%)###P-value


1###Knowledge about e-health###58 (37)###97 (63)###0.025

2###Knowledge about Open-Dental software*###37 (23.8)###118 (76.2)###0.036

3###Knowledge about database dental software program used now a day###21 (13.5)###134 (86.4)###0.041

4###Attended any seminar on e-health or not###47 (30.3)###108 (69.7)###0.039

5###Opinion about practice of tele-dentistry for distant places###59 (38.06)###96 (61.94)###0.015

6###Practice of tele-dentistry###Nill###155 (100)###--1

7###Opinion about practice of tele-dentistry in Pakistan###61 9(39.4)###94 (60.4)###0.001


Sr. No.###Uses of e-health###Frequency###(%)

1###Dental treatment plans###11###(20.7)

2###Supervising dentists for Prosthetic designs###7###(13.2)

3###Supervision of orthodontic services in the remote areas###9###(16.9)

4###Online appointments/consultation###25###(47.2)

5###Education of patients###1###(1.8)



Sr. No.###Barriers###Frequency###(%)

1###Lack of computer skills among dentists###27###(28.7)

2###High cost to develop the system###19###(20.2)

3###Dentistry requires manual work and cannot be done online###26###(27.6)

4###Patient compliance and satisfaction need physical presence of###10###(10.6)

###dentists, not online consultation

5###It will b an extra burden for dentists###12###(12.7)



Sr. No.###Comments about areas of e-health###Frequency

1###Basic health units /District and Tehsil headquarters###12



4###Operative dentistry###5

5###Community dentistry###1



Government of Pakistan is utilizing Information

Communication Technology for transformation of public health services at the door steps of common man. The main hub is in Holy Family Hospital and other four remote hospitals DHQ hospitals in Attock, DG Khan, Khushab and THQ hospital, Pindi Gheb are connected with the main HUB through satellite connectivity. In addition this centre is providing specialist consultations to 08 other sites in Punjab and rural Sindh. Rural telemedicine centres have enabled rural population to seek consultation, advice and treatment from specialist doctors in urban health centres, without having to travel hundreds of kilometres and spending their meagre financial resources on related transportation and accommodation. It is unfortunate, that there is no teledental or e-dental clinic in Islamabad.

Berndt J et al used e-dentistry to provide interceptive orthodontic services to disadvantaged children.24

According to national e-Health implementation survey Finland, electronic patient records are being managed in the country at a very large coverage and filmless picture archiving and communication systems are being used in 94% hospitals of the country to provide primary health care.25 Study done by Ramesh Nagarajappa, et al support the results of this study.26 Eino Ignatius and others also reported similar results.27

In the present study 30.3% of the respondents had attended seminar on e-health. Seminars on e-health promotion should be conducted in the country to increase knowledge of the health professionals to explore new horizons. In 2011 e-health association of Pakistan (eHAP) conducted e-Health awareness and advocacy seminar, but probably after that no seminar has been conducted in the area of Islamabad or conducted but not reported.28

10.6% of the respondents of the present study reported that patient compliance and satisfaction need physical presence of dental physician. Looms GA et al29 and Ajami S et al30 both explained similar reason of non-practicability of Electronic Medical Record (EMR).

28.7% of respondents reported that computer skill are required for operating e-dental software. These trainings are not available anywhere in Pakistan. A proper data exchange system is required for this purpose. Studies conducted by VH, Martinez-Garcia AI and Meinert DB supported the results of this study.31-34

13.5% (n=21) reported "yes" about knowledge of database dental software used now a days. Only 9 out of 21 respondents answered about database software correctly.

Teledentistry is a useful tool for both the patient and the dentist and can be applied in various sub-specialities of dentistry. It cuts down the time taken for multiple opinions by various specialists and is also more economical for the patient and the doctor. Prevention and early detection of any carious lesion or a soft tissue lesion is also possible through teledentistry. In endodontics it can help in accurate diagnosis of periapical lesion and treatment planning of carious teeth. In oral medicine and radiology it helps in diagnosing and framing a treatment plan of difficult cases by easy access to various specialists through transfer of radiologic images. In maxillofacial surgery it may be helpful for appropriate treatment of complicated cases by analysis of advanced dental imaging techniques (like CBCT) which are often not available in one centre. Orthodontists can see routine cephalometric analysis and supervise treatment.

Prosthodontists along with various computer aided diagnostic tools (like CAD, CAM) can design inlays, onlays and crown preparations.35,36


1 World Health Organization; Atlas eHealth country profiles: based on the findings of the second global survey on eHealth. December 2011.

2 The Office of the National Coordinator for Health Information Technology, United States Department for Health and Human Services. March 2012; Available at: portal/

3 Electronic health records. Healthcare Information and Management Systems. March 2012; Available at: http://www.himss. org/asp/topics_ehr.asp,

4 Personal health records Definition and position statement. Healthcare Information and Management Systems, 2007. March 2012; Avaiable at: phrdefinition071707.pdf

5 Agency for Healthcare Research and Quality.2009. Available at:

6 Fact Sheet: Computerized Physician Order Entry Leapfrog Hospital Survey. January 2014; Available at:

7 Minnesota Department of health; Understanding the Minnesota Interoperable Electronic Health Record Mandate; October 2015; Available at:

8 MedRunner Inc. e-Prescribing. 2011 November 22. Available at:

9 US Department of Health and Human Services. (n.d.). How does e-prescribing work? Health Resources and Services Administration. December 17, 2011.

10 Moja, L; Kwag, KH; Lytras, T; Bertizzolo, L; Brandt, L; Pecoraro, V; Rigon, G; Vaona, A; Ruggiero, F; Mangia, M; Iorio, A; Kunnamo, I; Bonovas, et al. Effectiveness of computerized decision support systems linked to electronic health records: a systematic review and meta-analysis. American journal of public health. 2014 Dec; 104 (12): 12-22.


12 Laurence Alpay, John Verhoef, Bo Xie, Dov Te'eni and JHM Zwetsloot-Schonk, et al. Current Challenge in Consumer Health Informatics: Bridging the Gap between Access to Information and Information Understanding. Biomedical Informatics Insights 2009; 2: 1-10.

13 Schweitzer J1, Synowiec C et al. The economics of eHealth and mHealth; J Health Communication. 2012; 17(1): 73-81.

14. Joseph Tan. E-Health Care Information Systems: An Introduction for Students and Professionals: Jossey-Bass; April 2012.

15 Luzanna Fung Lok Chee, Rashad Yazdanifard et al. Faculty of Management, Limkokwing, Ecommerce's Important Role in the Medical Sector. International Conference on Information Communication and Management IPCSIT, IACSIT Press, Singapore 2011 vol. 16 pg: 15-22.

16 Spriggs, Merele; et. al "Ethical Questions Must be Considered for Electronic Health Records". Journal of Medical Ethics. 2012 38 (9): 535-39.

17 "e-Health Part 1: current state of play." Australian Nursing Journal. May 2013 20 (2): pg: 20.


19 Chun-Ju Hsiao, Esther Hing, Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001-2013; NCHS Data Brief No. 143. January 2014; Available from:

20 "Open Dental Software - Appointments Module". Open Dental Software Inc. 2009-06-12.

21 "Open Dental Software - Family Module". Open Dental Software Inc. 2009-06-12.

22 "Open Dental Software - Account Module". Open Dental Software Inc. 2009-06-12.

23 "Open Dental Software - Manage Module". Open Dental Software Inc. 2009-06-12.

24 Berndt J, Leone P, King G et al. Using teledentistry to provide interceptive orthodontic services to disadvantaged children. American Journal of Orthodontics and Dentofacial Orthopedics 2008; 134: 700-706.

25 Paivi Hamalainen, Jarmo Reponen, Ilkka Winblad, Jarmo Karki, Maarit Laaksonen, Hannele Hypponen, Maarit Kangas; eHealth and eWelfare of Finland Checkpoint 2011; Available from:

26 Nagarajappa R, Aapaliya P, Sharda AJ, Asawa K, Tak M, et al. Teledentistry: Knowledge and Attitudes among Dentists in Udaipur, India. Oral Health Dent Manag. 2013; 12: 502.

27 Eino Ignatius, K. Makela et al. Use and Attitudes towards Teleconsultation in Dentistry; E-Health Telecommunication Systems and Networks, 2013; 2: 9-12 Available at: http://dx.doi. org/10.4236/etsn.2013.21002

28 Third International eHap Conference 2012; Volume 2, Issue 2 (April-June 2012); J Pak Med Stud 2012; 2(2): suppl (2) 1-24.

29 Loomis GA, Ries JS, Saywell RM Jr, Thakker NRJ Fam Pract et al "If electronic medical records are so great, why aren't family physicians using them?. 2002 Jul; 51(7): 636-41.

30 Ajami S, Ketabi S, Saghaeian-Nejad S, Heidari A. Requirements and Areas Associated with Readiness Assessment of Electronic Health Records Implementation. Journal of Health Administration. 2011; 14: 71-78.

31 Castillo VH, Martinez-Garcia AI, Pulido JR BMC Med Inform Decis Mak et al. A knowledge-based taxonomy of critical factors for adopting electronic health record systems by physicians: a systematic literature review. 2010 Oct 15; (10): 60.

32 Meinert DB. Resistance to Electronic Medical Records (EMRs): A Barrier to Improved Quality of Care. Informing Science: International Journal of an Emerging Transdiscipline. 2004; 2: 493-504.

33 Ford EW, Menachemi N, Phillips MTJ Am et al. Predicting the adoption of electronic health records by physicians: when will health care be paperless? Med Inform Assoc. 2006 Jan-Feb; 13(1): 106-12.

34 Branko Mihailovic, Milan Miladinovic, Biljana Vujicic et al. Telemedicine in Dentistry (Teledentistry) Advances in Telemedicine: Applications in Various Medical Disciplines and Geographical Regions 2011; 215-30.

35 Brullmann D, Schmidtmann I, Warzecha K, Dhoet BJ. Telemed: Recognition of root canal orifices at a distance - a preliminary study of teledentistry. Telecare. 2011; 17(3): 154-57.

36 Branko Mihailovic, Milan Miladinovic, Biljana Vujicic. Advances in Telemedicine: Applications in Various Medical Disciplines and Geographical Regions, Prof. Georgi Graschew (Ed.). In Tech, China. 2011. Chapter 11, Telemedicine in Dentistry (Teledentistry); pp. 215-30.
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Publication:Pakistan Oral and Dental Journal
Geographic Code:9PAKI
Date:Jun 30, 2016

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