Teledentistry in pre-pandemic and post-pandemic dental care: adoption, clinical evidence and unresolved limits

INTRODUCTION

The COVID-19 pandemic suspended routine dental care on a scale without precedent. Dental procedures generate aerosols, require close face-to-face contact and were among the first services to be restricted during lockdowns, which left triage, consultation and follow-up without an obvious delivery channel.(1) Teledentistry, the application of telecommunication and digital imaging to the delivery of dental care, education and consultation at a distance, became the instrument through which much of this interrupted care was rerouted.(2,3) It spans triage, remote diagnosis, specialist consultation, treatment monitoring and education, a breadth that makes it more than a single technology and that explains why its evidence is so unevenly distributed.(4) Before the pandemic the field had existed for decades, mostly as public programmes, school-based screening pilots and remote-area consultations; within weeks of the first lockdowns it moved from the margins to the centre of dental practice.(5)

Two delivery modes carry this practice. Synchronous teledentistry uses live video or telephone to reproduce a consultation in real time, whereas asynchronous teledentistry, also called store-and-forward, collects photographs, radiographs and questionnaire data for review by a dentist at a later time. The distinction determines cost, workflow and the questions that can be answered remotely, and it runs through every evaluation of the field.

The magnitude of that shift is measurable. Search interest in teledentistry increased fivefold during the pandemic, alongside a thirtyfold rise in queries for personal protective equipment for dentists and a fortyfold rise in queries about whether it was safe to visit a dentist.(6) Bibliometric data describe the same pattern: the published literature surged after 2020, and most of the 369 articles indexed on the topic appeared in the years that followed the first wave.(7,8) What remains contested is whether this expansion represented durable adoption or an emergency improvisation that receded as clinics reopened. Answering that question requires comparing three periods, the low pre-pandemic baseline, the pandemic surge and the post-pandemic equilibrium, rather than describing each in isolation.

The same comparative logic extends to the other questions that now define the field. The clinical value of teledentistry depends on how remote assessment performs against in-person examination, the reference standard against which diagnostic concordance, triage decisions and treatment planning have been measured.(9) Its practical organization depends on the modality chosen, synchronous video against asynchronous store-and-forward capture, and on the setting in which it is deployed, high-income against low- and middle-income countries, where infrastructure and workforce differ sharply.(10,11) Each contrast isolates a different reason why teledentistry might be adopted or abandoned, and why the evidence that supports it in one context does not transfer automatically to another. These contrasts matter for clinical decisions as much as for policy. A clinician deciding whether a photograph can rule out a carious lesion, a health system deciding whether to reimburse a video consultation, and a ministry deciding whether a remote pathway can extend care to a rural population are all asking the same underlying question, whether a remote channel performs the specific job delegated to it. Grouping the evidence by the job it was asked to do, rather than by technology or specialty, is what makes the comparison informative.

The objective of this review was to synthesize, through a comparative lens, the adoption, the clinical evidence and the unresolved limits of teledentistry after the COVID-19 pandemic. Specifically, it sought to compare the scale and durability of adoption before, during and after the acute phase of the pandemic; to compare the clinical evidence, mainly diagnostic concordance and triage, between teledentistry and in-person examination and between synchronous and asynchronous modalities; to compare adoption and barriers between high-income and low- and middle-income countries; and to identify the regulatory, technical, privacy and equity limits that remain unresolved.

METHODS

PubMed, OpenAlex and Crossref were searched for literature on teledentistry, telediagnosis, remote oral examination and related terms, combined with the concepts of adoption, diagnostic accuracy, synchronous and asynchronous delivery, and country income level. The core literature that sustains the synthesis was restricted to the period 2015 to 2023; earlier work was admitted when it supplied a definition, a methodological reference or a classic finding, as allowed for the supporting literature of a narrative review. No claim of exhaustiveness is made, and the review follows the SANRA scale for the quality of narrative review articles rather than systematic review procedures.( 12) Reference lists of included syntheses were scanned for additional primary studies, and the priority journals of the publishing house were searched for pertinent work; no pertinent in-window item was found there.

Studies were selected when they reported at least one of the following: population or provider estimates of teledentistry adoption or acceptability; diagnostic accuracy or concordance against an in-person examination; synchronous or asynchronous applications; or barriers and facilitators in a defined setting. Priority was given to original studies and to systematic reviews that reported a quantitative synthesis; narrative and integrative reviews were used to frame the evidence rather than to supply primary findings. The selected material was organized into five contrast axes: adoption before, during and after the pandemic; teledentistry versus in-person examination for diagnosis and triage; synchronous versus asynchronous modalities; high-income versus low- and middle-income settings; and unresolved limits. Within each axis, converging and diverging findings were weighed together with the design and quality of the source studies. Selected studies were logged in a working matrix that maps each axis to the claims it supports and to the studies that support or contradict them, so that the direction and the weight of the evidence behind each statement remain traceable to the bibliography.

Because definitions of teledentistry, outcome measures and reference standards vary across studies, only findings that used an explicit in-person comparator or a stated population denominator were treated as quantitative. The synthesis of the axes is summarized in (Table 1).

DEVELOPMENT

The synthesis is organized in five axes, each built on a contrast that separates a condition under which teledentistry succeeds from one under which it does not.

DISCUSSION

The central finding of this synthesis is that teledentistry survived the acute phase of the pandemic, but as a complementary layer of triage, screening and monitoring rather than as a substitute for the chairside examination. The adoption evidence, the diagnostic evidence and the unresolved limits all point in the same direction: teledentistry is strongest exactly where an in-person visit is least informative or least accessible, and weakest where the physical examination is the deciding input. That is why persistence after the pandemic is partial and conditional, and why the field has consolidated around asynchronous screening and remote monitoring rather than around a general remote practice.

This reading converges with the systematic syntheses available. The review of systematic reviews that anchors the diagnostic evidence reported accuracy that is good enough for referral and treatment planning but drawn from low-quality reviews, which is precisely the mixed picture described here.(9) Earlier validity reviews reached the same verdict of comparable but underpowered evidence.(39,40) On adoption, the reviews are more optimistic than the data they summarize: integrative reviews conclude that attitudes improved and that use will continue to rise, whereas the surveys and policy analyses assembled here show a gap between awareness and practice and a persistence that follows regulation and reimbursement rather than enthusiasm.(3,10,16,23,35) The difference is mostly one of emphasis. Reviews that weigh provider attitudes conclude optimism; those that weigh reimbursement, licensure and infrastructure conclude conditionality, and both readings can be true of the same period.

The contrast with telemedicine outside dentistry is instructive. In primary care, the pandemic produced a documented substitution of telehealth for in-person visits, followed by a partial reversion as clinics reopened, with equity effects concentrated in older, rural and low-income populations.(91-93) Dentistry shows the same arc but a shallower plateau, because a larger share of dental work depends on operative procedures that no remote channel can perform.(94,95) Where capture can be standardized, telemedicine achieves diagnostic accuracy that teledentistry has not yet matched: systematic reviews of diabetic retinopathy screening and of surgical site infection report high and reproducible accuracy because the image, the lesion and the grading rule are all standardized.(96,97) The intraoral photograph is less standardized, which explains why caries sensitivity in field studies sits at the moderate 60% to 63% while agreement within a single grader is almost perfect.(41) Standardization of image acquisition, not the diagnostic concept, is the main technical difference between teledentistry and the telemedicine specialties that have succeeded.

The synchronous and asynchronous contrast explains a second divergence, the one between patients and clinicians. In the single randomised controlled trial of a first remote orthodontic consultation, patients and practitioners diverged: patients found the remote encounter comparable, practitioners preferred the in-person one.(74) The same asymmetry appears across teleorthodontics.(75) Clinicians carry the diagnostic and medicolegal risk, and until that risk is defined, their caution is rational rather than merely conservative.(85,86) Patients, who experience the convenience and the avoided travel, respond to a different calculus.(27,98) This is a reminder that adoption data in this field are mostly cross-sectional and self-reported, and they support statements about association and perception, not about effectiveness or causation.(83)

The setting contrast carries the same caution across countries. High-income systems scaled teledentistry when policy and reimbursement moved, as the virtual dental home and Canadian and Australian experiences show.(31,34,36) Low- and middle-income systems adopted through consumer platforms and public telehealth networks with thinner infrastructure, which makes their adoption real but fragile.(11,77,78,82) The barriers are the same themes reported everywhere, workload, interoperability, usability and cost, but their severity scales inversely with resources.(83) Equity is therefore not a side effect of teledentistry but a structural property of it: the digital divide that telehealth reproduced during the pandemic applies with equal force to dentistry, and the populations that stand to gain most from remote care, older, rural and low-income groups, are the ones least equipped to use it.(93,99,100)

Several strengths support these conclusions. The review assembled evidence from three bibliographic sources across a defined window, applied explicit selection criteria, and treated as quantitative only findings with an in-person comparator or a stated denominator, which limits the risk of over-reading anecdotal reports. The comparative structure forced each claim to be weighed against its opposite, surfacing the divergences between patient and provider, between screening and definitive diagnosis, and between high- and low-resource settings that a purely thematic account would flatten. Two interpretative cautions apply throughout. Most adoption studies are cross-sectional surveys and most accuracy studies are single-centre convenience samples, so the associations reported here describe perceptions and performance under research conditions rather than effectiveness in routine care.(39,83) No finding in this review licenses a causal reading of the pandemic as the cause of adoption or of teledentistry as the cause of any oral health outcome.( 21)

The review has limitations that follow from its design. It is narrative rather than systematic, so selection and publication bias toward positive accuracy studies cannot be excluded; a preregistered living systematic review with multilingual search and grey literature would address this. Only three databases and, in practice, mainly English and Spanish records were used, which under-represents non-Western implementation; a multilingual strategy would capture more of the low- and middle-income experience. The heterogeneity of definitions, capture protocols and reference standards prevented any pooling of the accuracy data, so the quantitative anchors cited here are illustrative rather than pooled estimates; standardized reporting for teledentistry diagnostic studies, analogous to STARD, would make future syntheses possible. Most studies measure accuracy and acceptability, not the post-pandemic outcomes that matter for policy, such as reimbursement-driven utilization, avoidable referrals or oral health consequences; claims-based and implementation studies are needed to fill that gap. Finally, many primary studies are small and of low methodological quality, as the systematic reviews themselves note;(9,39) larger multicentre diagnostic studies would raise the certainty of the field.

The practical implications are concrete. Clinically, teledentistry should be positioned for triage, screening, post-operative follow-up and orthodontic monitoring, and not for the definitive diagnosis of conditions that require palpation, percussion or radiographs. Organizationally, asynchronous store-and-forward is the default for screening and monitoring, with synchronous video reserved for decisions that require a live exchange, a division already reflected in the evidence.(9) For policy, the conditionality of adoption argues for converting emergency measures into standing rules on reimbursement, licensure, consent and data protection, since those are the variables that predict whether teledentistry persists.(10,84,87) For education, the gap between awareness and practice suggests that training should emphasize image capture, triage criteria and the legal boundaries of remote care, not the technology itself.(101)

The primary-care experience adds two lessons that transfer to dentistry. First, the transition to telehealth was sustained only where workflows, scheduling and documentation were redesigned around the new channel rather than bolted onto existing routines, a finding consistent across primary care clinics during the first wave.(102,103) Second, patient satisfaction with remote encounters has been high for decades, which means satisfaction alone cannot discriminate between a good substitute and a convenient one.(98) Both lessons reinforce the caution that adoption and acceptability are necessary but not sufficient evidence for replacing the chairside.

Training deserves separate emphasis because it is the cheapest lever and the least used. The divergence between clinician caution and patient acceptance is partly a training problem: clinicians who are not confident in the triage criteria and the legal boundaries of remote care will rationally default to the chairside.(74,85) Structured curricula that teach image capture, referral criteria and documentation would convert the awareness that surveys already record into the practice they do not.(21) Remote orthodontic monitoring shows what this conversion looks like when it works, a defined capture protocol, an algorithmic check and a clinical review applied to a question narrow enough to be answered remotely.(67,69)

A secondary benefit aligns with the sustainability agenda of dental practice: telemedicine can reduce the carbon footprint of care by replacing patient travel, an effect documented for telehealth broadly and plausible for dental triage and monitoring in particular.( 104) The research agenda that follows is equally specific. Head-to-head trials of synchronous against asynchronous teledentistry for the same clinical question are scarce and should be prioritized, alongside economic evaluations that move beyond school screening and artificial-intelligence-assisted screening with defined governance.(62,76,90) Implementation studies in low- and middle-income settings should test whether low-cost consumer platforms can be converted into governed services without losing their reach.(105,106) Until those questions are answered, the responsible summary is that teledentistry persisted after COVID-19 because it solved a triage and monitoring problem, and it will earn a larger role only where its limits are recognized and regulated.

CONCLUSIONS

Teledentistry expanded from a marginal pre-pandemic practice to a pandemic-era surge and then settled into a partial post-pandemic persistence that is conditional on regulation and reimbursement. Remote assessment approaches in-person performance for triage, screening and oral lesion detection, but it remains less reliable for lesion staging and for conditions that require palpation, percussion or radiographs. Asynchronous store-and-forward dominates screening and monitoring, synchronous video supports real-time decisions, and the two modalities have rarely been compared directly. Adoption is real but fragile in low- and middle-income settings, where infrastructure, cost and connectivity concentrate the same barriers seen everywhere. Regulation, privacy, equity and the quality of the diagnostic evidence remain unresolved, and their resolution will determine whether teledentistry consolidates as a complement to the chairside examination or recedes with the emergency that launched it.

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