In contrast, videoconferences or real time consultations employ direct, on-line computer or satellite telecommunication technologies among specialists and GDP’s, telehealth assistants or patients located in remote communities, as long as the specialist remains online to provide instant support and supervision.

Studies have been developed using one or both of these methods depending on the research design and the study objectives but most of them were developed using “store and forward” methodologies. This is probably because they are less expensive and time consuming than videoconferences. A total of six studies in oral medicine are briefly reviewed. They are summarized in Table 2.1.

In the study reported by Leão and Porter [8], the sample was comprised of 20 patients referred to a dental institute for the diagnosis and management of oral mucosal disease. Digital images of oral lesion were captured by intraoral cameras and stored on videotapes, and thus, patients could view their own images on a color monitor. Photographs of each lesion were recorded, printed and stored in the patient’s clinical chart. Digital images and important clinical details were recorded in a standardized electronic letter and sent via e-mail as attached files. A group of judges was asked to compare the original and transmitted clinical images and to provide a professional diagnosis of each patient’s problem, which was compared to that of the attending consultant. Patients were asked to complete a questionnaire detailing their opinions of intra-oral camera utilization. They also were asked about the acceptability of viewing the images of their lesions.

They concluded that patient and clinician had good acceptability toward recording and electronically transmitting clinical images of common oral diseases and, therefore, aimed to develop the application of this methodology in the distant diagnosis of oral diseases.

Younai and Messadi [9] retrieved 78 complete charts from an oral medicine clinic and blindly evaluated the diagnostic agreement between the final diagnosis (gold standard) and a provisional diagnosis made independently and blinded by two oral medicine specialists based on an email with detailed information from the patients clinical chart. The final diagnosis or clinical hypotheses were omitted from the email. The objective was to test the accuracy of a clinical hypothesis based on the electronic communication of signs and symptoms and other relevant clinical data. The authors were concerned about the legal, ethical and financial impact of the increasing use of electronic communication between the health staff and patients. The authors compare their kappa index to some studies in teledermatology and found that even not using clinical pictures of oral lesions there was a moderate level of diagnostic accuracy. Although the impressive kappa results the authors alerted that their pilot study results “suggest that face-to-face patient examination is more accurate in establishing a correct diagnosis for oral mucosal pathologies than transmitted descriptive patient data alone”.

Torres-Pereira et al. [10] studied 25 patients during a 12-month period. All individuals lived in an underserved rural community distant from the main oral medicine reference clinic in southern Brazil. Authors developed an electronic form to record clinical data that was stored as a text-processing file. Oral lesions were documented using a professional digital camera with macro lens and ring flash. The clinical images were saved as JPEG files and then sent as an e-mail attachment to two consultants. Both consultants were oral medicine specialists and evaluated the images blinded and separately. It was requested that they record a maximum of two clinical hypotheses for each case, selected from a predefined list. Final diagnoses (gold standard) were compared to those provided by the remote clinicians to assess the percentage of total, partial or incorrect hypotheses.. The results suggest that digital photography can be an effective alternative in the clinical diagnosis of oral lesions, and primary care public health clinics may benefit from the use of telehealth in remote areas where oral medicine specialists are not available. The authors concluded that there was an acceptable diagnostic accuracy rate with use of oral lesions pictures sent by e-mail and in only one case it was necessary to refer the patient to a major center. They emphasized that the diagnosis of oral lesions using asynchronous technology could be an effective resource to manage referrals in the Brazilian public health system.