dental informatics

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Assessment of dental information systems in Europe: A

systematic review

Journal: Journal of Dental Education

Manuscript ID: Draft

Manuscript Type: Review Articles

Keywords: Technology, Information Technology < Technology

Author designated keywords: dental information systems, dental informatics, dental education

Journal of Dental Education

Submitted manuscript - not for distribution

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Assessment of dental information systems

in Europe: A systematic review

Abstract

Health information systems are becoming more widely used in medicine and lately in dentistry as well,

given the positive impact they can have on the quality of services delivered. The main purpose of

information systems is to help researchers, practitioners and educators in conducting their work. The

aim of this systematic review is to overview the current situation of dental information systems in

Europe.

A literature search was conducted on PubMed, ScienceDirect and Google Scholar using seven phrases.

These represent the words that are most commonly used in relation to this topic. The identified articles

were retrieved in Mendeley Desktop and checked against the eligibility criteria.

Results show that only 17 countries in Europe published articles on this topic. Dental education was the

most discussed topic. It evolved over time, from assessing the computer skills of dental students, to

assessing their attitudes towards the use of computerized educational tools. The use of information

systems in the fields of dental practice, research and electronic dental records was reported as well, but

represented by a smaller number of articles.

Research on dental information systems is conducted mainly in Western and Scandinavian countries,

with only three countries from Eastern Europe. All main topics in this field are discussed, but not

equally. Besides dental education, the retrieved articles do not offer a glimpse on the changes in the use

and implementation of information systems in dentistry. The fact that specific terms for each field were

not included represents a limitation of this study.

Keywords: dental information systems; dental informatics; dental education;

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BACKGROUND

Health information systems are becoming more widely used in medicine and lately in dentistry as well,

given the positive impact they can have on the quality of services delivered. The main purpose of

information systems is to help researchers, practitioners and educators in conducting their work (1). In

1981, the World Health Organization together with the FDI World Dental Federation set the

establishment of oral health information systems as a goal for the year 2000. Even though the WHO Oral

Health Program was created to help countries, developing such a system is a challenge in the majority of

countries in the world (2).

Oral health information systems can be divided into two categories, dental informatics on one hand and

information technology (IT) on the other (1). These are two distinct concepts which, nonetheless, aim at

helping practitioners, researchers and educators in solving practical problems (1).

Dental informatics refers to the ways in which the management of information, communication and

new technologies are applied in research, education and clinical practice (3). Informatics is the

“collection, classification, storage, retrieval and dissemination of recorded knowledge treated both as a

pure and applied science”. Dental informatics is concerned with information models and computing

applications, with the goal of improving patient outcomes. Therefore, it can be used in improving

diagnosis, the treatment and prevention of diseases and finally to preserve and improve the oral health

of people (4).

Secondly, dental informatics and its tools aim at increasing the cost-efficiency of dental care delivery.

Last but not least, it aims at contributing to the improvement of dental research and education, which in

turn translate to improved dental services and improved dental care. Some example of tools that are

used for these purposes are the digital radiography, decision-support systems, databases such as

MEDLINE, computer-assisted learning (CAL), simulations, online courses and many others (4).

Nonetheless, dental informatics is a discipline that has not yet grown to its full potential, but if the

challenges are managed successfully, the field will yield great results. Its four categories, model

formulation, system development, system installation and study of the system’s effects can influence

and inform the development of communication and information technology, the second component of

dental information systems (4).

The other constituent part of information systems, information technology, refers to the

implementation and evaluation of computer technology and telecommunications. Nonetheless, areas

such as software development and evaluation of systems is overlapping between the two categories (4).

The fields in which dental information systems are implemented in are the dental practice, dental

education and research. In the dental practice, it is used for both management and service delivery and

it refers to the existence of computerized systems, the use of digital radiography, of decision-support

systems, tele-dentistry and others. Nonetheless, it also refers to the use of e-mails, internet search and

retrieval of specialty literature (3; 5).

In dental education, the tools offered by information systems are used in addition to the classic teaching

materials. Use of technology in this case ranges from the students using online teaching materials,

retrieving information and specialty scientific literature from the internet, to simulations and taking care

of virtual patients (4; 7).The aim is to make students to be able to work independently and be more

autonomous. In this way, one of the goals of implementing such systems is to encourage the use of

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technology among dental students, who will be able to use it when they start practicing dentistry, as

well (6). One of the prerequisites of implementing it, is the assessment of students’ computer and

technological skills (7).

The field of research in dentistry involves reusing data gathered from the dental practice, data mining

tools, used to extract data from large and lastly, infrastructure and support to facilitate studying it (6).

Moreover, in order to assure the best dental care, its practice should be evidence-based. This involves

research to evaluate the best courses of action, materials and treatments for patients. Therefore, to be

able to give optimal care, dentists need to have access to the latest information that had been studied

(8).

Another important part of the computerization of the dental practice is the use of electronic dental

records, which collect data on the patients (3). Electronic dental records are an integral part in the

dental practice, but are also central to education and research, as well, since they can be used for the

practice of students and for epidemiological studies (9). Besides the high costs associated with

implementing it, electronic dental records rise the concern for patient privacy (10). Even so, a small

number of studies use this type of data, since a high proportion of the information is stored in an

unstructured way (4).

In Europe, around 1-2% of health budgets are allocated for information systems. It is thought that the

percent of investment in this field is directly proportional with the performance of the dental system (3).

Since there are stringent differences among countries in Europe and the performance of their health

systems (11), this study will offer a glimpse on the situation on the whole continent with respect to the

use of information systems in dentistry.

The aim of this systematic review is to assess, at the European level, which are the areas of information

systems that research in dentistry focuses on. Moreover, a geographical mapping of the existing studies

will be performed. Last but not least, the evolution of technology use and implementation will be

observed in European countries. To the best of our knowledge, there is no systematic review performed

on this subject that yields the same outcomes as the present paper.

METHODOLOGY

The study focused on the scientific literature dedicated to the general field of dental information

systems and the research made on this topics in Europe. Furthermore, we were interested in the

countries in which such research was conducted, in order to geographically map and observe the

evolution of information systems in European countries.

A search was performed on PubMed, ScienceDirect and Google Scholar using seven phrases. The words

included were chosen because they are the most commonly used in relation to this topic. The phrases

used were dental AND informatics; electronic AND (dental OR oral health) AND record; dental AND

information AND system; dental AND information AND technology; information AND system AND

dentistry; information AND technology AND dentistry. Each syntax was accompanied by the word

“Europe” in order to limit the search to articles published in this area.

The phrases were independently searched in the title and abstract of the articles in PubMed and

ScienceDirect. The word “Europe” was not limited only to the title and abstract. It was searched for in

the whole document, because not all articles contain the location of the article in the title. In Google

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Scholar the search was performed in the whole article, since the other available option was the title,

option which could have excluded some relevant results.

The articles were retrieved in Mendeley Desktop v. 1.13.8, in separate folders created for each data

base. After checking for and eliminating the duplicates, in the next phase, the titles and abstracts of the

papers were scanned to determine whether they met the inclusion criteria. The eligibility criteria

consisted of the article i) being written in English, ii) being conducted in an European country, iii) being

published in a peer reviewed journal, iv) regardless of the year of publication.

The full text version of the articles which met the inclusion criteria was searched in the database and if it

was not accessible, another search was made on the online library at the University of Iowa. If the entire

document was not found, the article was excluded.

The remaining documents were read and based on the subject of the research performed, placed in one

of the four categories. These categories were “Dental practice”, “Electronic Dental Record”, “Dental

Education”, “Research and Public Health”, which represent the areas in which dental information

systems are implemented. Although the literature mentions only three main categories for information

systems, a fourth category was created for electronic dental records, since it is a topic of particular

interest that supports the dental practice, education and research. In order to perform the division of

articles among the chosen categories, an Excel file was created in which the reference of the article was

copied. The year of publication, the aim and results of the research paper, as well as the country in

which the study took place were extracted in the same Excel file.

RESULTS

The search resulted in a total of 704 articles. After removing duplicates, 602 articles remained for the

scanning phase. Next, after applying the eligibility criteria for the title and abstract, 80 articles remained

relevant for our search. Out of these, 17 did not have the full text document available and 49 did not

meet the inclusion criteria after looking in the whole document. The process finally determined a

number of 31 articles that were relevant, which were included in the final analysis (Table 1).

Figure 1. Flowchart

The identified studies were performed in 17 European countries. The table below shows in which

countries the chosen topics were researched and how many articles were written in each country.

Table 1. Distribution of articles among countries

All articles were divided into one of the four categories, according to their content and the topics

approached. Five of the articles were included each into two categories, since two subjects were

discussed. The number of articles in each category can be seen in the table 2, while the topics

researched in each country can be seen in table 3.

Table 2. Number of papers for each category

Table 3. Distribution of topics among countries

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Dental education

The majority of research articles performed in countries from Europe were focused on the education of

dental undergraduate students, as well as on the continuing education of dentists and dental nurses.

Specifically, the studies were investigating either the computer skills of students and professionals, their

acceptance level with regards to information system use, or the implementation and effectiveness of

information systems in universities or dental practices.

Information systems associated with dental education was discussed in all identified countries, except

Romania, Belgium and Greenland. The first article on this topic was published in 1988 in England and

concluded that computers have, indeed, an important role in the management of dental education. It

also describes the informational system that has been running by that time for seven years.

Evolution

Four articles were written before 2000, in England, Ireland and Sweden. The studies report students not

being very familiar with computers and the lack of inadequate training as a barrier to implementing such

systems in the educational curricula.

The majority of articles (n=15) were written after 2000. Besides looking at students’ and professionals’

ability to operate computers, they test the acceptability and effectiveness of e-courses, interactive-

learning modules, computer-assisted learning (CAL), and virtual patients. All studies reported these tools

to be effective and accepted by their recipients, as well as by the teachers. Few studies performed at the

beginning of the 2000s still reported students’ low computer skills, but the situation seems to change in

articles published later.

Dental practice

Eight articles were written on this topic, in England, Sweden, Ireland and Romania, between 2001

(England) and 2015 (Romania). The studies looked at information system users’ acceptability level and

attitudes. Two studies (England and Romania) assessed, the extent to which dental practices are

equipped with information systems, results showing that in England the majority of practices have or

plan to install one, while in Romania, very few practices use such a system for administrative or clinical

tasks.

Other articles investigated other types of tools that are aimed at increasing the efficiency and safety of

the dental practice, such as tele-dentistry, a decision support system for diagnosis and a decision

support system for teeth color matching. Only one article (England) was focused on the standardization

of measurement in dentistry.

Evolution

Since this topic is more recent, its evolution is not very obvious. Even so, in recent years, the studies

investigated the use of more complex technological systems, such as decision support systems and tele-

dentistry.

Research and Public Health

Seven articles were published on this topic, between 2001 and 2014. The studies evaluated the quality

and utility of data obtained from dental practices, the systems used to gather the data which can be

used for public health interventions or for the strategic planning of dental services. Also, in this category

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is included one study conducted in Greenland, which used data obtained from an information system to

assess the dental health of children.

One study compared electronic data collection with traditional handwritten data and concluded that the

electronic method reduces the workload. In the Scandinavian countries (Norway, Sweden, Denmark),

dental professionals were asked whether they would agree to use data gathered at their practice of

research, since almost 100% of practices use an information system, and the majority would be willing

to reuse the data. Even so, data is not recorded in such a way that could be directly extracted, but it

would need a standardized form.

Evolution

The studies retrieved on this topic do not offer a glimpse on its evolution in Europe. One reason could be

the fact that articles were published only in the last 14 years.

Electronic Dental Records

Only two articles were written on this topic. One research paper used data collected in the Czech

Republic and the other one used data collected from Norway, Sweden and Denmark. Both studies were

conducted in 2013 and looked at the use of electronic dental records and compared methods of data

collection to see which one is better.

In the Czech Republic, the authors compared three methods of storing patient data, one paper based

and two electronic, one of which controlled by voice. The study concluded that although the paper

based was the most rapid, it was not the best for the storage of documentation and neither for the

dentist. The study conducted in the Scandinavian countries emphasized the fact that patients’ dental

records are stored electronically.

Evolution

Since both studies were published in the same year, no evolution with respect to this topic can be

observed.

Table 4. Summary of articles included in each category

Figure 2. Geographical mapping of countries in which research was performed

DISCUSSION

The systematic review shows that all topics are tackled in continental Europe, in 18 out of the 50 states.

These are mainly countries in the Western part of the continent, Scandinavian countries and a few from

the former Soviet Union. The results show that indeed, information systems are in relation with the

performance of health systems, since poorer countries in Europe, mainly from the Eastern part, do not

have studies on this topic (3).

The most recurrent topic, dental education, receives particular attention, probably since it may have the

greatest outcomes with respect to fully implementing information systems in dental practices. If dental

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students are trained using technology, there is a bigger chance that they will choose to take full

advantage of the benefits associated with it when they start practicing dentistry. The study of students’

and professionals’ attitudes towards the use of technology yields suggestions for improvement, in order

to design the information systems according to their needs and preferences.

Regarding students’ computer skills, up until the year 2000 were reported to be insufficient. In the

articles published later, students’ skills became better, since computers became more widely used with

the passing of years. Also, after 2000, this topic included research on various teaching methods that had

a technological component, showing that information systems started to develop.

For the use of information systems in dental practice, three high-income countries and one middle-

income country (Romania) conducted studies that looked at technological tools used by dentists. In

recent years, the technology seems to evaluate, with studies looking at decision support systems (12;

13) and tele-dentistry (14).

Then, the study of research in the field of dentistry was performed only in high-income countries.

Authors looked at the quality and utility of data obtained from dental practices (15), the systems used to

gather the data which can be used for public health interventions or for the strategic planning of dental

services (16; 17). Only one study performed in Greenland (18) used data gathered at national level from

the information system. This is in concordance with the literature which affirms that few studies take

use of this kind of data, mainly because of the lack of standardized data collection (19). In this regard,

one study conducted in England tackled this issue and emphasized the importance of a clinical minimum

data set for oral health and the standardization of measurement (20).

Electronic Dental Records were the least studied in Europe, with only 2 studies focused on this topic (19;

21). Nonetheless, this result does not necessarily imply the fact that EDR are not implemented in

Europe.

Nonetheless, in depth research is needed to accurately assess the situation of information systems in

Europe. This systematic review stands as a basis for future research aimed at summarizing the current

research on each of the topics included in this paper.

The present study also draws the attention on the fact that more studies should be conducted in this

field, so as to contribute to the research base on this topic. Specifically, this would contribute to

improvement of information systems in dentistry and would also incentivize researchers, professionals

and finally policy makers to take action towards the digitalization of the dental practice and dental

system.

LIMITATIONS

The search did not include specific terms for each category of dental information system, which

accounts for one of the limitations of this paper. This lead to the exclusion of certain articles that focus

specifically on those subjects, such as information systems used in dental schools curricula. An in depth

search is needed to review all studies made on each dimension covered by dental informatics and

information systems in dentistry.

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Then, the articles were assessed against the eligibility criteria and were divided into categories only by

one person. This accounts for selection bias, which could have been eliminated if two persons would

have participated in this process.

Another limitation was the unavailability of the full-text document of all articles. Last but not least, more

articles may have been published on this topic in the languages used in the countries where studies

were performed. Nonetheless, these were not included since one of the eligibility criteria consisted of

the articles being written in English.

CONCLUSION

The present systematic review revealed that few countries in Europe, only 18 out of 50, are concerned

with studying the field of information systems used in dentistry. Moreover, in majority, only Western

and Scandinavian countries, with a few exceptions from Eastern Europe countries report on the use of

information systems.

Results show that the most studied topic is dental education, with an emphasis on students’ and

professionals’ attitudes towards the use of technology in teaching, as well as the acceptance level of

different information system tools. With regards to the dental practice, the studies performed in four

countries looked at the acceptance level of users, but also investigated the efficiency of certain

computerized systems.

For research, the identified studies evaluated the quality and utility of data obtained from dental

practices and the systems used to gather the data. Then, the electronic health records topic was the

least discussed topic, only in the Scandinavian countries and in the Czech Republic.

The results indicate that programs aimed at supporting and encouraging the implementation of

technology in dental practices are needed, since information systems are associated with improved

patient care and services management.

BIBLIOGRAPHY

1. Dental Informatics: An Emerging Biomedical Informatics Discipline. Schleyer, T.K. 2003, Adv Dent Res

17, pp. 4-8.

2. WHO. Oral Health. World Health Organization. [Online] June 21, 2015.

http://www.who.int/oral_health/action/information/surveillance/en/index1.html.

3. Information Systems in Dentistry. Masic, F. 2012, Acta Inform Med. 20(1), pp. 47–55.

4. Dental informatics : A cornerstone of dental practice. Schleyer, T., Spallek, H. 2001, The Journal of the

American Dental Association, pp. 605-613.

5. The Role of Information Technology and Informatics Research in the Dentist-Patient Relationship.

Kirshner, M. 2003, Adv Dent Res 17, pp. 77-81.

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6. Digital clinical records and practice administration in primary dental care . Wagner, I., Ireland, R.,

Eaton, K. 2008, British Dental Journal volume 204, no.7.

7. Information and communication technologies in dental education: students’ perceptions. Warmling,

A., Amante, C., Ferreira de Mello, A. 2014, RSBO, pp. 25-33.

8. Computer literacy and attitudes among students in 16European dental schools: current aspects,

regionaldifferences and future trends. Mattheos, N., Nattestad, A., Schittek, M., Attström, R. 2002, Eur

J Dent Educ, pp. 30–35.

9. SOMWeb-Towards an Infrastructure for Knowledge Sharing in Oral Medicine. Falkman, G.,

Torgersson, O. 2005, Studies in Health Technology and Informatics.

10. Validity of an Information and Communication Technology System for Data Capture in

Epidemiological Studies. Carvalho, J.C., Bottenberg, P., Declerck, D., van Nieuwenhuysen, J.P,

Vanobbergen, J., Nyssen, M. 2011, Caries Research, pp. 287–293.

11. Ethics and the Electronic Health Record in Dental School Clinics. Cederberg, R., Valenza, J. 2012,

Journal of Dental Education vol. 76 no. 5 , pp. 584-589.

12. Papanicolas, I., Smith, P. Health Systems Performance Comparison. Berkshire : World Health

Organization, 2013.

13. Decision Support System in Dental Practice. Evaluation of Dental Professionals Acceptance Level.

Dana, G., Petrişor, M. 2012, Acta Medica.

14. A decision support system for color matching in dentistry. Prejmerean, V. 2015, Studia Universitatis.

15. Application of teledentistry in oral medicine in a community dental service, N. Ireland. Bradley, M.,

Black, P., Noble, S. 2010, British Dental Journal.

16. Scandinavian systems monitoring the oral health in children and adolescents; an evaluation of their

quality and utility in the light of modern perspectives of caries management. Skeie, M. S., Klock, K. S.

2014, BMC Oral Health.

17. Validity of an information and communication technology system for data capture in epidemiological

studies. Carvalho, J., Bottenberg, P. 2011, Caries Management.

18. Use of a national database for strategic management of municipal oral health services for Danish

children and adolescents. Hansen, I., Foldspang, A., Poulsen, S. 2001, Community Dentistry and Oral

Epidemiology, 29(2), , pp. 92–98.

19. Dental health status and development trends among children and adolescents in Greenland.

Petersen, P. E., & Christensen, L. B. 2006, International Journal of Circumpolar Health, 65(1), pp. 35–44.

20. Electronic dental record use and clinical information management patterns among practitioner-

investigators in The Dental Practice-Based Research Network. Schleyer, T., Song, M., Gilbert, G., Rindal,

D., Fellows, J., Gordan, V., Funkhouser, E. 2013, Journal of American Dental Association 144(1), pp. 49–

58.

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21. A clinical minimum data set for primary dental care. Ireland, R. S., Jenner, A. M., Williams, M. J.,

Tickle, M. 2001, British Dental Journal, 190(12), pp. 663–7.

22. Evaluation of voice-based data entry to an electronic health record system for dentistry. Chleborad,

K., Zvara, K., Dostalova, T., Hippmann, R., Ivancakova, R., Zvarova, J., Psutka, J. 2013, Biocybernetics

and Biomedical Engineering, 33(4), pp. 204-210.

23. From Information Technology to Informatics: The Information Revolution in Dental Education.

Schleyer, T.K., Thyvalikakath, T.P., Spallek, H., Dziabiak, M.P., Johnson, L.A. 2012, Journal of Dental

Education 76(1), pp. 142–153.

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Table 1. Distribution of articles among countries

Country No. of articles

England 9

Sweden 7

Ireland 5

Denmark 4

Germany 4

Greece 3

Norway 3

Romania 3

Czech Republic 2

The Netherlands 2

Finland 2

Belgium 1

Hungary 1

Spain 1

Austria 1

Latvia 1

Greenland 1

Table 2. Number of papers for each category

Dental education Dental practice Research and Public Health Electronic Dental Records

19 articles 8 articles 7 articles 2 articles

Table 3. Distribution of topics among countries

Country Dental education Dental practice Research and

Public Health

Electronic Dental

Records

England x x x

Sweden x x x x

Ireland x x

Denmark x x x

Germany x

Greece x

Norway x x x

Romania x

Czech Republic x x

The Netherlands x

Finland x

Belgium x

Hungary x

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Spain x

Austria x x

Latvia x

Greenland x

Table 4. Summary of articles included in each category

Dental education Most recurrent topic (19 articles)

Published first in 1988 in England

Investigated computer skills of students and dental professionals

Investigated the acceptance of information systems in education

Reported on implementation and effectiveness of information systems

Before 2000 – students’ lack of IT skills

After 2000 – acceptability and effectiveness of e-courses, CAL, virtual

patients, etc.

Dental practice Eight articles in four countries

Investigated users’ acceptability level and attitudes

The extent to which dental practices are equipped with information

systems

Investigated tele-dentistry, decision-support systems

Standardization of measurement in dentistry

Research and Public Health Seven articles

Assessed the quality and utility of data obtained from dental practices

Evaluated systems used to gather the data

Performed a study using data gathered through the EDR

Evaluated dentists’ willingness to reuse data gathered through the EDR

Electronic Dental Records The least researched topic (2 articles)

Investigated use of EDR

Compared ways of storing patient data

Evaluated dentists’ willingness to reuse data gathered through the E

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Figure 1. Flowchart

Records identified through database

searching

(n = 704)

Incl

ud

ed

E

lig

ibil

ity

Ide

nti

fica

tio

n

Records after duplicates removed

(n = 602)

Title + abstract screening

(n = 602)

Records excluded

(n = 521)

Search for full-text

(n = 81)

Articles excluded

(n = 49)

Studies included in

qualitative synthesis

(n = 32)

Full-text

not

available

(n = 17)

Inclusion

criteria not

met in full-

text

(n = 32)

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Figure 2. Geographical mapping of countries in which research was performed

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dental informatics

Documents

use of information systems

fields of dental practice

electronic dental records

fdi world dental federation

review articles keywords

systematic review journal

europe published articles

retrieved articles