F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.172573.1Research ArticleArticlesCould telescreening be an alternative for referring urgent dental cases in children? A before-and-after study.
[version 1; peer review: 2 approved with reservations]
DornellasAna PaulaConceptualizationData CurationFormal AnalysisFunding AcquisitionInvestigationMethodologyResourcesValidationVisualizationWriting – Original Draft Preparationhttps://orcid.org/0000-0003-4213-3824a1Diniz Santos CastroMaria EduardaInvestigationVisualization1Ramos PintoMarceloFormal AnalysisVisualizationWriting – Review & Editinghttps://orcid.org/0000-0002-6672-87371MulderJulia Nascimento da SilvaVisualizationWriting – Review & Editing1MalletAdrianaMethodologySoftware1GarridoDeiseValidationWriting – Review & Editing1HaddadAna EstelaMethodologyProject AdministrationSupervisionValidationVisualizationWriting – Review & Editinghttps://orcid.org/0000-0002-0693-90141
Pediatric Dentistry, University of São Paulo Faculty of Dentistry, São Paulo, São Paulo, 05508-060, Brazilanapauladornellas@usp.br
Teledentistry has emerged as a promising strategy to improve access to urgent dental care for pediatric populations, particularly in underserved areas; however, evidence regarding the agreement between telescreening and in-person assessment for pediatric dental emergencies remains limited. This before-and-after study, nested within a randomized controlled clinical trial, evaluated the level of agreement between diagnoses and risk classifications obtained through telescreening and in-person consultation in children aged 3 to 13 years presenting with dental pain. All participants underwent synchronous telescreening using a standardized questionnaire and were randomized into two groups; the present analysis included 130 children allocated to telescreening followed by an in-person consultation, which was performed by a blinded examiner unaware of the telescreening results. Agreement between treatment decisions (urgent vs. elective) was assessed, and pain outcomes were monitored at baseline, 7 and 15 days using the Wong–Baker Faces Pain Scale. Agreement between telescreening and in-person evaluation was observed in 49.2% of elective cases and 26.9% of urgent cases, with infrequent changes in treatment decisions, including 6.9% of cases reclassified from urgent to elective and 0.8% from elective to urgent. Pain scores showed a significant reduction over time (p < 0.001), with median values decreasing to zero at both follow-up assessments. These findings indicate that telescreening demonstrates good agreement with in-person evaluation for the identification and management of pediatric dental appears to be a viable and effective alternative for initial screening and referral, although adherence to subsequent in-person care remains an important consideration.
TeledentistryRemote consultationToothachePain measurementHealth equityDigital health strategies.Conselho Nacional de desenvolvimento científico e tecnológico - CNPq2036632802873606This research was supported by the National Council for Scientific and Technological Development – CNPq, CNPq/MCTI/FNDCT, 18/2021 - Band A - Emerging Groups, whose coordinator is Professor Ana Estela Haddad. Process number 422896/2021-7 and call CNPQ no 03/2021 - Productivity grant in technological development and innovative extension - DT n. protocol 2036632802873606.The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Introduction
Teledentistry has been considered a practical and economically viable strategy to provide healthcare to underserved populations, including socially unassisted individuals who live in remote or rural areas, or who simply do not have access to routine dental care.
1–
5
In this context, telescreening has been linked to better patient referral, to shorter waiting lists, and to prioritization of care. Based on accurate remote screening analysis, individuals can receive appropriate primary care in a correct and individualized manner, being referred to teleassistance, or to the dental office when mandatory, minimizing unnecessary travel.
6,
7
However, there is still a lack of consistent scientific evidence of the advantages of telescreening in dentistry, and it is necessary to further investigate the possibilities of using telecommunication tools in health care planning, particularly to benefit of municipalities that do not have the human resources to provide specialized care, and populations in general, that do not have access to a specialist.
8
Based on the aspects quoted above, this study aimed to investigate whether telescreening can be a viable alternative for pediatric dental emergency referrals, applying the comparison between the results of remote evaluations and traditional in-person evaluations. This research assesses the level of agreement, through a before-and-after study design.
Material and method
Clinical trial registration: This study was registered in the Brazilian Clinical Trials Registry (ReBEC) under the registration number RBR-523hrsx. It was registered on June 8, 2022. Participant recruitment and data collection were conducted between April 2024 and July 2024.
Study design
This study is part of a controlled, blinded (evaluators), randomized clinical trial, involving 260 children aged 3 to 13 years, in dental emergency situations. All participants investigated were users of Basic Health Units, hospitals, schools or dental clinics, and residents of Carangola city, at Minas Gerais state, in Brazil. After the first contact through a messaging application, a link to access the SIAS/SMART platform was sent to each patient. All individuals were previously evaluated in a teleconsultation (“before”), by a previously trained researcher and then randomized and divided into two groups: G1, consisting of 130 patients treated through teleconsultation, and G2, consisting of 130 patients treated through teleconsultation and also in person. The in-person evaluation (“after”) was performed by a dental surgeon, who did not know the outcome of the teleconsultation.
The professional performed the anamnesis and clinical examination using a specific dental record and, at the end, answered YES or NO to the urgency of patient’s clinical situation. The dental condition that led to the patients’ inclusion in the study was treated by the researcher, and the patient’s other needs were met by the referral to the health service unit to which they belonged.
The follow-up of patients in G1 and G2 was carried out for 7 and 14 days, using specific scales to assess the absence (or presence) of pain (Wong-Baker scale).
Inclusion criteria
Children aged 3 to 13 years old, with dental pain who sought emergency care at dental clinics;
Patients with sufficient internet quality enabling a synchronous consultation.
Exclusion criteria
Patients who did not attend the in-person consultation, when allocated to group G2;
Patients with difficulties accessing the internet.
Recruitment
When arriving at a Basic Health Unit, school, hospital or dental clinic outside of office hours, those parent (or legal guardian) of the children with dental pain was able to gather information through a poster fixed outside the facility, containing the contact information of one of the researchers, with a phone number and the ethics committee approval number. The service was also advertised on social media, such as: Facebook groups, WhatsApp groups, as well as on school printed calendars.
Allocation
Patients were allocated to one of the treatment groups according to a sequence generated by statistical software MedCalc
® (MedCalc Software 15.11, Ostend, Belgium) and distributed in sealed brown envelopes in blocks of four. The envelopes were opened immediately after initiating the teleconsultation.
Training of examiners/researchers
The examiners and researchers were properly trained to conduct the research. This training involved a 4 hours course on dental emergencies in children, and a 4 hours calibration training course on how to apply the questionnaire.
Prior to the start, the researcher explained the study and the use of teledentistry, to the entire professional team of Basic Health Units.
Intervention
Synchronous teletriage was performed using the customized NuTes-FOUSP teleconsultation platform (SIAS-SMART), which complies with the Brazilian General Data Protection Law (LGPD)
10 and a questionnaire, containing objective questions to determine whether or not the case in question was a dental emergency. The time taken to complete the questionnaire was directly related to the specific time spent obtaining the answers.
At the clinical stage of the research, the time between telescreening and the in-person dental consultation was not counted, to prioritize attending the urgent cases immediately after the synchronous consultation.
The clinical situations listed below (ADA, 2020)
11 were considered dental emergencies:
Irreversible pulpitis;
Pericoronitis;
Abscess or localized bacterial infection, resulting in localized pain and swelling;
Tooth fracture, resulting in pain or causing trauma to soft tissues.
Dental trauma involving avulsion and/or luxation.
Lost, broken, or irritating restoration causing gum irritation, requiring a temporary restoration;
Extensive caries or defective restoration causing pain;
Pain involving the need to replace the temporary filling of the endodontic access opening;
Perforated or ulcerated oral mucosa involving the need to cut or adjust a wire or orthodontic appliance.
The clinical situations listed below were not considered dental emergencies:
Initial or maintenance dental examination;
Routine X-ray;
Dental prophylaxis;
Routine periodontal therapy;
Orthodontic procedures other than those necessary to treat acute problems (e.g., pain, infection, trauma);
Extraction of asymptomatic teeth;
Restorative dental procedures, including treatment of asymptomatic carious lesions;
Cosmetic dental procedures.
Sample size
Before-and-after studies are considered observational studies and use a preliminary diagnostic test, in order to decide about the treatment of examined patients. These individuals undergo another diagnostic method, and then, the treatment decision can be reviewed. As this before-and-after study is nested within a randomized clinical trial (RCT), the primary outcom e of the RCT was considered for the sample size calculation, and the two experimental groups as n = 260. However, only the group evaluated using both methods (telescreening + in-person consultation) was eligible for this study. Therefore, the before-and-after study sample consisted of 130 patients.
Data analysis
Descriptive analytics of the diagnosis of urgent treatment needs were performed, using the teletriage questionnaire alone, and also in combination with the in-person consultation. For these analyses both for remote and in-person examinations, the possible treatment decision outcomes were: (i) urgent treatment needed, or (ii) elective treatment possible. The frequency of variation in treatment decision was calculated taking into account that changes can be from: (i) urgent to elective treatment, or (ii) from elective to urgent treatment. Explanatory variables related to children, such as gender, age (randomization extracts) and caries experience will be used in the analyses. The primary outcome of this study was any variation in the clinical treatment decision, after the in-person consultation.
Prevalence ratio (PR) values and their respective confidence intervals (95% CI) were calculated and univariated and multiple regression analyses were performed. The significance level was set at 5% and the data were analyzed using Jamovi and Rstudiol softwares.
Results
For the before-and-after study, 130 patients that underwent telescreening sessions were also invited to attend the in-person evaluation, but 21 patients missed this subsequent appointment.
When comparing possible treatment decisions, the frequency of agreement between evaluations as elective treatment was 49.2% (n = 64), while the change from elective to urgent treatment was 0.8% (n = 1). Similarly, a frequency of 26.9% (n = 35) with agreement on the need for urgent treatment was identified, while the change from urgent to elective treatment occurred in 6.9% (n = 9) of cases. Regarding those patients who did not attend the in-person evaluation, 11.5% (n = 15) were classified as urgent in the teletriage, and 4.6% (n = 6) as elective treatment.
Fluxogram 1 - Decision change Fluxogram
Source: The Author
In the pain assessment of these individuals of the 130 patients initially evaluated, 109 could be evaluated after 7 days, and 103 after 15 days.
The median scores were 0 at all times, with differences only in the interquartile range (IQR), which was 3 at baseline, while at 7 and 15 days it was 0; and in the maximum values found, which were 5 at baseline, 4 at 7 days, and 1 after 15 days. When the Friedman test (for categorical – non-parametric – and paired data) was performed, we found a statistically significant difference (p < 0.01). Paired comparisons, using the Durbin-Conover post-hoc test, showed differences between the results of the facial scale at baseline compared to both 7 days (p < 0.01) and 15 days (p < 0.01); and a difference between the results at 7 days vs. 15 days (p = 0.02) (
Tables 1,
2 and
3).
Description.
“FACES SCALE INITIAL”
“FACES SCALE 7 DAYS”
“FACES SCALE 15 DAYS”
N
130
109
103
Missing
0
21
27
Median
0.00
0
0
Standard deviation
1.89
0.669
0.0985
IQR
3.00
0.00
0.00
Minimum
0
0
0
Maximum
5
4
1
25th percentile
0.00
0.00
0.00
50th percentile
0.00
0.00
0.00
75th percentile
3.00
0.00
0.00
Source: The Author.
Repeated measures ANOVA (Non-parametric).
Friedman
χ
2
df
p
80.2
2
<.001
Fonte: O autor.
Source: The Author.
Pairwise comparisons (Durbin-Conover).
Statistic
p
“Faces Scale - Initial”
-
“Faces Scale - 7 Days”
8.76
<.001
“Faces Scale - Initial”
-
“Faces Scale - 15 Days”
11.06
<.001
“Faces Scale - 7 Days”
-
“Faces Scale - 15 Days”
2.30
0.022
Source: The Autor.
Statistical analysis confirmed a significant difference in pain scores between initial moments, after 7 days and after 15 days, indicating that telescreening was effective in identifying and managing dental emergencies, with a notable reduction in pain throughout the follow-up period.
Discussion
The study demonstrated that telescreening showed a high rate of agreement between in-person and remote diagnoses, which reinforces the effectiveness of this method of evaluation in pediatric dental settings. These findings are consistent with the results obtained by Mendes et al.,
12 who also observed significant agreement between remote screening and in-person clinical evaluation in a similar study. The high reliability of dental telescreening, as reported by both studies, suggests that this tool may be a viable solution for circumstances with limited access to care.
In addition, the study revealed that telescreening allows a faster response to urgent cases, especially in rural and remote areas. This finding is in line with a study,
13 which pointed out that teledentistry can speed up the assessment and referral process and also can have a significant impact on children’s oral health, especially in underserved populations, as discussed by both studies.
The before-and-after (pre- and post-intervention) study design used in this research is an approach to evaluate the effectiveness of dental telescreening in children. This type of design allows for direct comparison of results, before and after the implementation of teletriage, providing a clear view of the changes that occurred due to the intervention. Studies
14 have also used this design to investigate the validity of oral health interventions, demonstrating that this methodology is effective in capturing significant improvements in both clinical and operational parameters. The comparison of pre- and post-intervention results, both in the present study and in previous studies, reinforces the validity of the research design used, showing that teletriage can effectively improve the identification and referral of dental emergency cases in pediatric populations.
15
Currently, the Brazilian public health network is being structured to provide urgent dental care. In the past, the absence of this approach in Brazil was a significant gap in oral health care, especially in remote and disadvantaged areas. As highlighted by some authors, the lack of specialized dental emergency services can lead to delays in treatment and worsening oral health conditions. In this context, the results of this study on the reliability of telescreening emerge as a crucial contribution. By offering a viable alternative for the evaluation and referral of urgent cases, this method can mitigate the lack of emergency dental services, providing faster and more efficient access to treatment. The data indicate that it is not only capable of adequately identifying emergencies, but also of improving pain management, which can be a significant advance for the oral health system in Brazil, where the implementation of urgent and emergency services is still in initial stages.
16,
17
However, the study also points to important challenges, such as patient adherence to the in-person phase, which is essential to validate the results of dental telescreening. Failure to attend the in-person appointment can compromise the continuity of dental treatment and, consequently, patient’s safety. This suggests that, for the effective implementation of programs like this, it is necessary to develop strategies that ensure patient adherence to all stages of care.
18
Another relevant point is the need for continuous training for professionals who perform dental telescreening, ensuring that remote assessments are as accurate as in-person ones. This study indicates that, with proper training, it is possible to achieve a high level of agreement between both methods but, on the other hand, it also highlights the importance of clear and specific protocols to guide treatment decisions, minimizing the risk of misclassifications. In addition, it is essential to incorporate the principles of health literacy, ensuring that both professionals and patients clearly and effectively understand the exchanged information, facilitating assertive communication and more informed decisions.
19
Conclusion
Teletriage proved to be a viable alternative for screening dental emergencies in children, with high agreement in terms of diagnoses and risk classifications, when compared to in-person evaluation. The significant reduction in pain indicates that telescreening can be effective in managing emergencies, contributing to the efficiency of dental care. However, challenges such as adherence to the in-person phase must be considered in order to optimize implementation process, and also clinical practice.
Ethics and consentEthical considerations
All procedures involving human beings and data were conducted in accordance with the ethical principles established in the Declaration of Helsinki. The study fully complied with international guidelines for research involving human subjects, ensuring confidentiality, integrity, safety, and autonomy of the participants. The design of this study (both the before-and-after study and the randomized clinical trial) was approved by the Research Ethics Committee of the School of Dentistry, University of São Paulo (CAAE #: 46974821.9.0000.0075) on June 1, 2021. It was also submitted to the Brazilian Clinical Trials Registry (ReBEC), with the statement code RBR-523hrsx. The study design was written following the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guideline.
9
The study was divided into the following stages: (1) questionnaire validation, (2) randomized clinical trial, and (3) before-and-after study, each of them with specific methodologies.
Consentiment
For this phase of the study, participants were included upon acceptance of the Informed Consent Form (ICF) sent during the remote stage, accessed through a digital link. The legal guardians of participants allocated to the in-person consultation group (G2) also signed the ICF on site.
In both phases, questionnaire validation and the before-and-after study nested within the clinical trial, the children’s age and level of comprehension were taken into consideration during the consent process.
Consent was obtained in two ways:
In writing, when the legal guardian accessed and signed the document provided through the digital link;
Verbally, in cases where the participant or guardian was unable to read or access the link, with the procedure documented in accordance with the approved ethical guidelines.
Additionally, children in the G2 group who demonstrated sufficient understanding were invited to sign an in-person Assent Form, resulting in two signed documents (ICF + Assent Form) for each participant in this group.
Confidentiality
The data collected was stored using specific procedures to ensure secrecy and confidentiality of the research participants’ information. Only remote consultation platforms with robust security standards that comply with Federal Law No. 13,709 of August 14, 2018 (General Personal Data Protection Law – LGPD) were used 10. In addition, the subjects surveyed were able to withdraw from the study at any time, without any prejudice.
Data availability
The data presented in this study are available on request from the corresponding author due to confidentiality agreements with the participants involved in the research. Our data statement is complete and adheres to the journal’s guidelines. Access to the data is restricted to protect participant privacy. Researchers wishing to access the data must submit a formal request to the corresponding author, including their full name, institutional affiliation, research purpose, specific data required, intended use, and measures for ensuring data security and participant confidentiality. Additionally, applicants must provide ethical clearance or approval from their institution to ensure compliance with data protection regulations. Requests will be evaluated on a case-by-case basis, and access will be granted under specific conditions approved by our Institutional Review Board (IRB). For further inquiries, please contact
anapauladornellas@usp.br.
Reporting guidelines
The completed CONSORT 2010 checklist has been deposited in an external public data repository (Zenodo). Title of the checklist: “CONSORT 2010 Checklist – Telescreening for Pediatric Dental Emergencies”.
20 The checklist is openly available under a Creative Commons Zero (CC0 1.0) license and can be accessed via the following DOI:
https://doi.org/10.5281/zenodo.18097473.
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10.5281/zenodo.1806188210.5256/f1000research.190311.r458386Reviewer response for version 1SainiRavinder S1Refereehttps://orcid.org/0000-0001-5578-9406
King Khalid University, Abha, Saudi Arabia
Competing interests: No competing interests were disclosed.
1. Statistical reporting should be improved. Discuss both positive and negative results equally. Include new references to make work up-to-date .
2. Suggestions for improving scientific quality :provide additional correlation and validity for diagnostic information. Clearly define study design. Address attrition bias. Provide complete statistical results of analyses. These recommendations would enhance the technical validity of the study design and conclusions.
3. Description of the intervention, inclusion criteria and statistics allow a basic understanding of the methods used. Provide statistics to describe agreement between diagnoses . provide clarification of regression analyses performed,. Give more detailed description of data management and missing data. This will help in reproducibility.
4. Statistical tests are appropriate for your pain score data (non-parametric tests like Friedman test and post-hoc comparisons). Limitations include insufficient presentation of agreement statistics for diagnostic comparisons like (e.g., Cohen's kappa and sensitivity/specificity). interpretation of findings are overstated . (e.g., consensus and effectiveness). More detailes statistics and conservative interpretation are needed.
5. Telescreening seems helpful for early assessment . claims are overstated compared to the actual data. Agreement was expressed in percentages . provide official diagnostic accuracy statistics. Pain reduction cannot be completely attributed to telescreening. Use caution when interpreting the conclusions due to study design and statistical limitations.
6. The kappa values referred as "agreement" are very low for any diagnostic or screening tool (49.2% for elective & 26.9% for urgent). Authors described the numbers that shifts between "good agreement" and "high rate of agreement." This makes it hard to accept the claim that telescreening works. Rephrase all the statements regarding this.
7. Results: "For the before-and-after study, 130 patients that underwent telescreening sessions were also invited to attend the in-person evaluation, but 21 patients missed this subsequent appointment." Also: "In the pain assessment of these individuals of the 130 patients initially evaluated, 109 could be evaluated after 7 days, and 103 after 15 days."
Describe how this attrition may affect the results. Compare characteristics of lost to follow-up patients (if possible) to see if there is bias. Mention this as major limitation in the d iscussion section. Consider doing sensitivity analyses if possible. Highlight ways to improve adherence for future studies.
8. Materials and methods : Please elaborate on the "standardized questionnaire" (ie. Provide the domains it covered ? What were example questions? What were scoring/decision criteria?). Please describe "4 hours calibration training course in more detail. (What did this involve?) Also, was inter-rater reliability among tele-examiners calculated? Also you can include the questionnaire as an appendix.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
DornellasAna PaulaUniversity of São Paulo, Brazil
Competing interests: no conflict of interest.
442026
We sincerely thank the reviewer for the detailed and constructive evaluation of our manuscript. We greatly appreciate the insightful comments, which contribute to a more precise interpretation and positioning of our study. Regarding the statistical reporting and interpretation of results, we acknowledge the importance of presenting both positive findings and limitations in a balanced manner. We emphasize that the intention of the study was to explore the feasibility and clinical behavior of telescreening in a real-world pediatric setting. For this reason, the analysis was designed to be primarily descriptive, reflecting clinical applicability rather than formal diagnostic validation. We recognize that this approach requires cautious interpretation, and we agree that the findings should be understood within this exploratory framework.
Concerning the validity of diagnostic information, we would like to clarify that the study was not designed as a diagnostic accuracy study. Instead, it aimed to observe agreement patterns and decision-making behavior in clinical practice. While formal measures such as sensitivity, specificity, and Cohen’s kappa would strengthen diagnostic validation, they were not part of the original study design. We therefore emphasize that our findings should not be interpreted as evidence of diagnostic accuracy, but rather as an initial assessment of clinical concordance in a telehealth context.
With regard to the description of methods and statistical analyses, we agree that additional detail supports reproducibility. The manuscript provides a structured description of the intervention, inclusion criteria, and analytical approach sufficient to understand the study framework. However, we acknowledge that further granularity, particularly regarding data management, regression analyses, and agreement statistics, would enhance reproducibility, and we identify this as a limitation of the present work.
Regarding the analysis of agreement, we recognize that expressing agreement primarily as percentages limits the strength of interpretation. We therefore reinforce that these results should be interpreted descriptively, without implying diagnostic validation. The observed agreement levels reflect a preliminary understanding of concordance within a clinical workflow, rather than a validated screening tool.
In relation to the pain outcomes, we agree that pain reduction cannot be attributed solely to telescreening, as multiple clinical and contextual factors may have contributed. The results should therefore be interpreted as an observed clinical evolution rather than a direct causal effect of the intervention.
Concerning the interpretation of agreement levels, we acknowledge that the terminology used in the manuscript may have suggested stronger agreement than supported by the data. We emphasize that the reported values should be interpreted cautiously and within the limitations of the analytical approach, avoiding classifications that imply high diagnostic reliability.
Regarding attrition and loss to follow-up, we recognize that this represents an important limitation. The reduction in sample size over time may introduce bias and affect the robustness of longitudinal findings. While the study reflects real-world clinical conditions, we acknowledge that strategies to improve follow-up adherence and analyses comparing retained versus lost participants would strengthen future research.
With respect to the telescreening instrument and examiner calibration, we clarify that the questionnaire was based on clinically established criteria for dental emergency triage and applied in a pragmatic care setting. The calibration process consisted of structured training aimed at standardizing clinical judgment; however, formal inter-rater reliability was not calculated, which we recognize as a limitation.
Finally, regarding the conclusions, we emphasize that the findings should be interpreted within the scope of an exploratory study. While telescreening appears to offer potential as a supportive tool in early assessment and referral, we recognize that the claims must remain cautious and that further studies using robust diagnostic accuracy designs are necessary.
We thank the reviewer once again for the valuable comments, which contribute to a more balanced and transparent interpretation of the study, particularly within the context of open peer review.
10.5256/f1000research.190311.r454487Reviewer response for version 1QariAlaa Husni1Refereehttps://orcid.org/0000-0002-4552-3417
Department of Preventive Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia
Competing interests: No competing interests were disclosed.
The manuscript asks whether pediatric telescreening can substitute (or safely complement) conventional pathways for identifying and referring urgent dental cases, using a before-and-after comparison.
The manuscript cites relevant foundational and regional teledentistry literature; however, some conclusions overstate “high agreement,” terminology is imprecise, and including more recent pediatric diagnostic agreement or accuracy studies could improve the overall context.
Materials and Methods: The before-and-after comparison nested within an RCT is acceptable for feasibility and agreement exploration, but the design is not optimal for diagnostic agreement assessment (no kappa/accuracy framework).
The absence of the full telescreening questionnaire limits replication; please describe its elements and validation.
Statistics: The agreement analysis only uses percentages and does not include formal agreement statistics (like Cohen's kappa, sensitivity/specificity), and sometimes the interpretation suggests a stronger diagnostic validity than the analysis actually support.
Data: This does not meet full reproducibility standards, particularly for agreement analyses.
Conclusion: Claims of “high agreement” and effectiveness in managing emergencies are stronger than warranted by the modest concordance rates and lack of formal agreement metrics.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
No
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
Reviewer Expertise:
The areas of focus include dental public health, teledentistry and digital health interventions, health services research, and the evaluation of diagnostic and screening tools in dentistry.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
DornellasAna PaulaUniversity of São Paulo, Brazil
Competing interests: no conflict of interest.
442026
We would like to thank the reviewer for the careful reading and thoughtful comments on our manuscript. We appreciate the relevance of the points raised, particularly regarding the interpretation of the findings and the methodological positioning of the study. Regarding the Introduction, we acknowledge the observation that some terms may suggest a stronger level of agreement than that supported by the analyses performed. These expressions were initially used to reflect the clinical applicability observed within the study context. However, we agree that more precise terminology is appropriate, and we emphasize that the findings should be interpreted as indicating clinically relevant agreement within an exploratory framework.
Concerning the study design, we would like to clarify that the objective was not to conduct a formal diagnostic accuracy study, but rather to evaluate the feasibility and behavior of telescreening in a real-world clinical context, particularly for the referral of urgent pediatric dental cases. The before-and-after comparison nested within a randomized clinical trial allowed us to observe clinical decision-making dynamics under practical conditions, which we consider a strength of the study, although we recognize that it does not replace classical diagnostic validation designs.
With respect to the telescreening instrument, we acknowledge that a more detailed description may enhance reproducibility. The instrument was developed based on widely accepted clinical criteria for dental emergency triage, incorporating aspects such as pain intensity and duration, associated clinical signs and symptoms, and functional impact. It was applied in a clinical care setting, with pragmatic validation derived from its use in practice, although it has not undergone formal independent validation.
Regarding the statistical analysis, we agree that formal agreement measures such as Cohen’s kappa, sensitivity, and specificity could provide a more robust assessment. However, we emphasize that the study was designed as a descriptive and exploratory analysis, aiming to reflect the applicability of telescreening in a clinical setting rather than to establish formal diagnostic accuracy. Therefore, the use of agreement proportions was considered consistent with the study objectives.
In terms of data availability, we recognize the growing importance of transparency and reproducibility in scientific research. The data presented in the manuscript accurately reflect the findings of the study, and we remain open to sharing additional information upon reasonable request, in accordance with ethical considerations.
Finally, regarding the interpretation of results and conclusions, we emphasize that the findings should be understood within the scope of an exploratory study assessing the feasibility of telescreening in pediatric dentistry. While the results suggest relevant clinical potential, further studies using more robust methodological designs are necessary to formally establish diagnostic accuracy.
We thank the reviewer once again for the valuable contributions, which enrich the scientific discussion of this topic, particularly within an open peer review model that promotes transparency and constructive dialogue.