DentView – a digital self-care guidance tool for oral health

DentView is a digital oral health self-care guidance tool that aims to improve the oral health of dental care customers and thus their general health. The aim of the product is to improve the accessibility and content of self-care guidance in oral health care and to harmonise the provision of preventive care. Preventive action aims to reduce the costs of health care. [1] 

The product consists of a virtual kiosk with a smart mirror function, a dispenser for oral care supplies (toothbrush, dental floss, plaque disclosing tablet and virtual kiosk’s touchscreen cleaning cloth) and the MyDentView home application. Professionals use the DentViewPro reporting portal, where customers generate anonymous data.  

A virtual kiosk is usually installed in the waiting room of a dental clinic. The purpose of the virtual kiosk is to provide information and act as a tool for motivation related to oral health. The program has different educational paths for different age groups, parents of expectant families and customers using orthodontic appliances or dentures. The product also includes its own menu for outpatient use related to information on the connections between oral health and general diseases. The purpose is to motivate and instruct patients in oral care and to collect and report oral health data for use by health care professionals. [1] 

Research evidence relating to the product under evaluation 

Pilot studies 

A pilot study (2021) conducted by Syrjä wanted to discover the opinions of oral health professionals about the DentView virtual kiosk. The staff of the Dental Teaching Unit in Oulu and dental students were asked to respond to a survey on the contents and convenience of the teaching paths for users of different ages of the virtual kiosk. Eighteen people replied to the survey, one of whom replied to two surveys concerning different teaching paths.  

DentView received mainly positive feedback. According to the respondents, it is well suited as a tool for promoting oral health. Different teaching pathways take well into account users in different life situations and of different ages. According to the respondents, use of the programme before the appointment is useful. Development proposals included guidance on the use of an electric toothbrush and supplementing the accessories with xylitol products. The respondents hoped that attention would be paid to the placement of the virtual kiosk at the reception: the virtual kiosk is easily accessible to end users and the environment is easy to clean. [2] 

In a pilot study by Havela et al (2021), DentView was used for six months in three oral health care units in Oulu. During this time, patients were asked for feedback on the use of the virtual kiosk. Taking the survey was voluntary and took place anonymously. Sixty patients took the survey. The majority of the patients agreed that DentView was useful and easy to use, and that it provided the necessary information to promote oral health. The programme motivates you to brush your teeth and use dental floss. It seemed that the respondents’ background (e.g. smoking or education) had no relevance to the content of the responses. [3] 

Piloting a virtual kiosk in North Karelia 

A virtual kiosk was piloted between 9/2021 and 1/2022 in the North Karelia Wellbeing Services County (Siun sote) in the dental clinics at Lieksa and Rantakylä. Feedback on its use was requested from both customers and professionals. Sixteen responses were received from the customers from Lieksa with an average score of 4.56/5 and 134 from Rantakylä with an average score of 4.48/5 (the scale of the survey was 1 = completely disagree and 5 = completely agree).  

The professionals provided a total of nine responses and felt that the use of DentView was mainly a useful tool in their work. The tooth brushing guidance was commended, and professionals felt that using the device is especially suitable for young people. However, the use of the virtual kiosk must be better marketed to patients and attention must be paid to its placement so that it is easily accessible. The professionals wanted an appointment book for the virtual kiosk so that the device would not be left unused due to waiting time. [4] 

Feedback surveys made by DentView 

DentView has conducted two feedback surveys for oral health professionals on the virtual kiosks, HomeApp and the data portal, to which 160 and 146 responses were received. Some of the respondents felt that they may not be able to give sufficient oral self-care guidance to patients during appointments. The respondents believed that the counselling and accessibility of oral care can be increased by digital means. They were well aware of the contents of the different teaching pathways and recommended the use of a virtual kiosk for patients and other oral health care units. The respondents said that positive feedback had also been received from the patients. However, most of the respondents were not able to say whether DentView had a positive impact on working hours and efficiency.  

Professionals had less knowledge about the use of the MyDentView home app. The professionals knew that the data portal collected regional data and that it could be used to improve oral health care services, but most had not logged into the service and thus did not utilise the data. [1] 

Literature reviews 

A systematic review examined the use of mobile phone applications in oral health by patients of all ages. The review included all types of studies published in English between 2000 and 2021. Studies focusing on the development of mobile applications for oral health were excluded.  

Out of 977 studies, 45 were selected, focusing on oral health promotion, diagnostics, orthodontics, behavioural management, trauma, and others. In this review, it was observed that several RCT studies reported significant reductions in dental plaque (9/23, 39%) and improvements in gum health (6/23, 26%) in mobile phone app users compared to controls. Therefore, mobile phone applications can be used for oral health education and teaching patients good home care skills. The review also found that the majority of the studies involved (25/45, 56%) were focused on children (under 10 years of age) and their families, as well as young people between 10 and 19 years of age. The studies in this review did not include the elderly or adults. 

The use of mobile applications in oral health is increasing among patients, mainly children and adolescents. Improvements in oral hygiene, information and health behaviour can be made through the use of mobile applications, but more research is needed. [5] 

References 

Teija Niiranen, Director of Oral Health Care at the Päijät-Häme wellbeing services county, says in the reference letter that with the help of DentView they have improved the quality and accessibility of preventive work. The use of DentView has also reduced their workload, as preventive work has been carried out by a “virtual oral health professional”. [1] 

Katja Lepistö, Director of Oral Health Care at the Satakunta wellbeing services county, writes in her reference letter that DentView has effectively helped in preventive and health-promotion work. Patients have enthusiastically welcomed the digital self-care guidance tool. [1] 

Ongoing and future studies 

The report of Päivi Havela’s pilot study has not yet been published. Two thesis projects related to this study are still ongoing. [1] 

A new study coordinated by Umeå University is planned for autumn 2024. At the time of the assessment, a study in the city of Halmstad was already underway. [1] 

The University of Turku will start a follow-up study on the possible improvement in the self-care level of orthodontic patients measured by certain clinical indicators. A thesis project in the University of Turku is also ongoing, focusing on the DentView experience of patients undergoing orthodontic treatment. [1] 

Students attending the Oulu University of Applied Sciences are also planning thesis work related to the use of DentView. [1] 

Summary  

The product-related data was mainly related to the use of a virtual kiosk in oral health care units. Based on these pilot studies and surveys, the use of the virtual kiosk appeared promising. At the time of the assessment, there was little evidence of the use and benefits of the oral self-care guidance mobile application for patients and the data portal for professionals.  

According to literature, data science and big data analytics can provide practical insights and assistance in making strategic decisions about the healthcare system. This will help build a comprehensive picture of patients, consumers, and health care services. Data-driven decision-making opens up new opportunities to improve the quality of health care. [6] 

More comparative research and longer-term monitoring are needed to ensure that the health of oral health care customers improves when they have access to a digital self-care guidance tool and the services have been improved with the help of data portal information. Longer-term monitoring is also needed to ensure that the use of the digital self-care guidance tool has led, for example, to shorter customer appointments, as professionals no longer need to spend as much time on self-care guidance. 

DentView has been commercially available since 2021 without any reported operational safety incidents. The virtual kiosk is a CE certified product, which fulfils the technical requirements laid down for it, such as the criteria for electrical safety and wireless communications. [1] 

The company also assesses the risks associated with the use of the product on a separate risk management form, and the risk assessment is part of the documented monthly process of the company. In addition, the company has a defined process covering corrective measures in case of malfunction of the device. [1] 

When a customer reports a malfunction of the device by telephone or email, the information is stored and the malfunction resolved as soon as possible with the help of maintenance personnel or software updates. [1] 

The virtual kiosk is connected to the network with a separate SIM card and only conducts one-way data transfer to a Google Firebase server. Connection interruptions in remote locations have caused synchronization issues that may affect the timely updating and availability of data. To solve the challenge, the company has integrated a functionality into the system that enables temporary data storage for local devices. [1] 

The company has taken into account the hygiene-related aspects of the use of the virtual kiosk with appropriate measures [1]. 

DentView operates on a leasing basis. The cost of using the product consists of the installation fee for the virtual kiosk and the monthly leasing fee for the use of the service. The installation fee includes an installation date during which the company may install 1-3 devices. No separate fee will be charged for user training. [1] 

The monthly lease includes the following services:  

• operating a virtual kiosk 

• dispenser and 200 self-care kits. Additional kits can be purchased under a separate agreement.  

• use of the MyDentView home app for customers 

• software updates 

• new versions 

• access to customer data for one person in the organisation 

• if necessary, change of location of the virtual kiosk and dispenser [1]. 

1-2 employees in the procuring organisation will be trained in the use of the device. Their duties include:  

• filling the dispenser with self-care kits 1–2 times a week 

• cleaning the device at the end of the day 

• turning on the device in the morning and turning it off in the evening [1].  

On the basis of the information provided by the service provider, it appears that the cost of using the service is reasonable when compared to providing a corresponding service by other means. 

The assessment was carried out using the list of data security and data protection requirements for social welfare and health care procurement and the response material provided by DentView Ltd [8,1]. 

Risk management and data security testing 

DentView has created a brief general guideline to maintain data security of an Android-based implementation. DentView has designated a person responsible for safety of the device. Backup copies of the database are automatically taken. 

Log management 

The logs contain information about the error states encountered by the device. DentView can monitor all active sessions and receives alerts about device malfunctions. Malfunctions may include, for example, Bluetooth malfunction and failure of requests sent by the device. 

User management 

The DentView virtual kiosk has one Android user account with a standard view of the DentViewservice through the ‘Fully Kiosk’ software. Service mode and other functions on the device are password protected. The data collected by the kiosk is anonymous. MyDentView for home use does not make use of user accounts and the statistics collected are anonymous. The data portal is accessed through user accounts that administrators can add, edit, or delete. The administrators can also view all collected data from the devices. Ordinary users of the data portal are able to process data from their own location and cannot see other users or other locations. 

Hardware 

The operating system of the device is Android 9. The device is password-locked into Kiosk mode, allowing visitors to access only the DentView app. The device is not connected to the health care organization’s network. The device is connected with a HTTPS encrypted connection to the database using the built-in 4G modem. The modem uses a SIM card. In addition, the device has a Bluetooth connection to the dispenser unit. DentView performs hardware upgrades remotely through the application that manages the Kiosk mode. 

Data protection 

The device collects anonymous data stored on servers located in the EU. Through DentView’s web portal, customers can view the data collected from the kiosk using the identifiers assigned to them. DentView uses anonymous data for its research. DentView may delete collected data from its databases at the separate request of the client organisation. Normally, the device does not store the collected data but transmits it directly to the database by means of a modem. If the connection to the Internet is poor at the installation site, the device may also store the data locally. The data is stored at rest in encrypted form in both situations.  

Other considerations 

The last security update of the Android 9 operating system was made in 2022, at which time its official support was also terminated. 

General guidance on procurement  

During the purchase phase it is always important to contact the IT management, data security specialist and data protection specialist of the organisation. Please discuss with them whether the product in question fulfils your requirements. In addition, we recommend that wellbeing services counties utilise the European Union Agency for Cybersecurity’s (ENISA) data security procurement guidelines [9]. 

DentView offers dental care units a study package consisting of a virtual kiosk and a dispenser. Customers can download the MyDentView home application to their own device using the QR code on the self-care kit in the dispenser. In addition, a DentViewPro reporting portal is available to professionals through a web browser. [1] 

Virtual kiosk 

The virtual kiosk is a stand-alone device about two metres in height with a 32-inch interactive touchscreen that uses software developed on the Android platform. The graphical user interface on the virtual kiosk provides users with information, instructions, and interactive exercises on oral care. [1] 

The product has been tested in various operating environments, such as dental clinics and educational institutions, and it has also been piloted extensively. The pilots have provided information on the functionality and usability of the device. [1] Based on the user feedback collected on the usability of the virtual kiosk (25,000 pcs), several measures have been taken to improve the accessibility of the service, in particular for users with different accessibility requirements. Special user groups have been taken into account in the design process of the virtual kiosk, for example, with the following functionalities [1]:  

• the product supports several languages and the instruction language can be changed 

• letter size can be increased 

• important information is not expressed merely by colours 

• sound effects have been used to distinguish between right and wrong answers 

• large content designed for the visually impaired 

• the hearing impaired have the opportunity to listen to the content 

• learning paths that utilise gamified content and animations have been designed for child users 

• the user interface does not contain flashing elements.  

In addition, the use and usability of the virtual kiosk have been studied in a thesis completed in 2021, which also examined the features of the application in relation to the accessibility requirements of WCAG 2.1 [7]. Feedback on the accessibility of the virtual kiosk can be given using the online form on the company’s website [1].  

MyDentView home application for customers  

The MyDentView home application is a web application that can be downloaded using the QR code on the dispenser kit. After scanning the QR code, the customer can use the home application five times. The application provides content on dental care for both adults and children and contains material similar to the virtual kiosk, but with added information. Dental care paths for adults are more comprehensive and detailed than those for children, which are mainly designed for proper brushing of teeth. [1,3] In the home application, you can provide feedback on the use of the product [1].  

The company has assessed the accessibility of the MyDentView home application itself. The home application does not fully meet the WCAG 2.1 AA level requirements, but the shortcomings have been identified. The accessibility statement is publicly available on the company’s website [11]. You can provide accessibility feedback in MyDentView home application or using a form on the company’s website. The company will respond to the accessibility feedback within 14 days. [1] 

DentViewPro reporting portal for professionals 

The reporting portal is a service for professionals provided through a web browser. It allows you to view anonymous customer and professional feedback collected by the virtual kiosk and the MyDentView home app from different locations where DentView products are used. [1] The company has self-assessed the accessibility of the service and the accessibility statement is available on the company’s website. The accessibility assessment shows that the website does not fully meet the WCAG 2.1 AA level requirements. [11,12] It is possible to provide feedback on the use of the product on the DentView website [1,11]. You can provide accessibility feedback through the DentViewPro reporting portal or on a form on the company’s website. The company will respond to the accessibility feedback within 14 days. [1]  

General guidance on procurement 

The purchasing organisation shall take into account the accessibility requirements set out in the legislation in force at the time [10,12,13]. 

Interoperability 

Integration into patient information systems and the Omakanta personal data reserve is planned for the product. Reports from the DentViewPro reporting portal can be downloaded in PDF format. [1] 

Technical functionality 

The company has continuous processes for receiving error messages and correcting errors. DentView uses the Bitbucket version control system to manage changes and versions of the application. For error handling, DentView makes use of system log monitoring and automated reporting. In addition, the company has an established process to restore the software to a previous functioning state, if necessary. [1] 

The installation of new software updates takes place in the background. Users will be notified of major updates in advance by email. The aim is to arrange the updates so that they do not interfere with the user’s sessions. [1] 

Training and product support 

The purchasing organisation appoints persons responsible for the device who will be trained in the use of the device. DentView can also arrange guidance. [1] 

Product distribution 

DentView is used at about 45 clinics in 11 wellbeing services counties in Finland. It has also been tested in Sweden at Malmö University and in one county [1].

1. The Digi-HTA questionnaire filled out by the company, not public information.
2. Syrjä, S. DentView suun terveyden virtuaalikioski: pilottitutkimus. (2021). https://urn.fi/URN:NBN:fi:oulu-202202111210. Accessed on 10.5.2024
3. Havela P., Vuontisjärvi R., Rantala A., Laitala M.-L., Karki S. Digital oral health promotion in public health care: a pilot study. In: EADPH Congress Abstracts 2022 https://www.eadph.org/download/eadph-congress-abstracts-2022/ Accessed on 10.5.2024 
4. DentView virtuaalikioski apuna suun terveyden edistämistyössä. https://innokyla.fi/fi/toimintamalli/dentview-virtuaalikioski-apuna-suun-terveydenedistamistyossa. Accessed on 10.5.2024
5. Väyrynen E, Hakola S, Keski-Salmi A, Jämsä H, Vainionpää R, Karki S. The Use of Patient-Oriented Mobile Phone Apps in Oral Health: Scoping Review. JMIR Mhealth Uhealth. 2023 Sep 6;11:e46143. doi: 10.2196/46143. PMID: 37672331; PMCID: PMC10512118.
6. Subrahmanya SVG, Shetty DK, Patil V, Hameed BMZ, Paul R, Smriti K, Naik N, Somani BK. The role of data science in healthcare advancements: applications, benefits, and future prospects. Ir J Med Sci. 2022 Aug;191(4):1473-1483. doi: 10.1007/s11845-021-02730-z. Epub 2021 Aug 16. PMID: 34398394; PMCID: PMC9308575.
7. Ignatius, L. 2021. Designing Visual Appearance to an App for Kids Designing DentView Oy’s Home Mobile App. https://urn.fi/URN:NBN:fi:amk-2021060414391  
8. National Cyber Security Centre: Information security and data protection requirements for social welfare and healthcare procurements. Available at: https://www.kyberturvallisuuskeskus.fi/en/ncsc-news/instructions-and-guides/information-security-and-data-protection-requirements-social  Accessed on 10.5.2024
9. The European Union Agency for Cybersecurity Procurement Guidelines for Cybersecurity in Hospitals. Available at: https://www.enisa.europa.eu/publications/good-practices-for-the-security-of-healthcare-services Accessed on 10.5.2024 
10. Act on the Provision of Digital Services 306/2019 (Available only in Finnish). Available at: https://www.finlex.fi/fi/laki/alkup/2019/20190306 Accessed on 10.5.2024
11. DentView saavutettavuusseloste (accessibility statement) https://dentview.fi/feedback/  Accessed on 10.5.2024
12. Regional State Administrative Agency of Southern Finland, Accessibility supervision unit. The requirements of the Act on Provision of Digital Services. Available at: https://www.webaccessibility.fi/requirements-of-the-act-on-the-provision-of-digital-services/  Accessed on 10.5.2024
13. Act on public Procurement and concession contracts 1397/2016 (Available only in Finnish). Available at: https://www.finlex.fi/fi/laki/alkup/2016/20161397  Accessed on 10.5.2024

Petra Falkenbach, Head of Assessment, FinCCHTA 

Jari Haverinen, Special Planning Officer, FinCCHTA 

Raija Järvinen, Special Planning Officer, FinCCHTA 

Teemu Mustola, Special Planning Officer, FinCCHTA 

Tommi Hanhela, Information Security Expert, University of Oulu 

Jere Kinnunen, Information Security Expert, University of Oulu 

Antti Koskela, Information Security Expert, University of Oulu